Form P-9A Medical Checklist for Transfers

OMB 0970-#### [Valid through MM/DD/2020] Office of Refugee Resettlement

U.S. Department of Health and Human Service Medical Checklist for Transfers, Rev. 09/05/2016

OFFICE OF REFUGEE RESETTLEMENT

Division of Children’s Services

MEDICAL CHECKLIST FOR TRANSFERS

IDENTIFYING INFORMATION
UC’s Name:       A#:      	Completed By(name and title):       Date Completed:      
INSTRUCTIONS
This checklist must be completed by a medical coordinator or other medical staff within three (3) business days identifying the need for a transfer. If “No” is checked for any of the below questions, do not transfer the child without consulting the ORR Medical Team. The FFS must also be consulted in accordance with ORR policies and procedures. The completed checklist should be uploaded to the UC Portal under “UAC Documents” and the paper copy stored in a secure location. Do not include a copy of this checklist with the child’s transfer documents as it contains confidential medical information.
CHECKLIST
		Meets Transfer Criteria	Does Not Meet Transfer Criteria
Has the initial medical exam been completed?		Yes	No
Have results from all lab tests been received?		Yes	No
Is the child up-to-date on immunizations?		Yes	No
Does the child have enough medications to last through the transfer process, plus an additional 3 days?		Yes NA	No
Is the child free of all medical conditions that require specialist care (such as pregnancy, or epilepsy, or heart disease)?		Yes	No
Is the child currently clear of the following symptoms/conditions?
Fever		Yes	No
Rash		Yes	No
Cough		Yes	No
Neck stiffness/Confusion		Yes	No
Diarrhea/Vomiting		Yes	No
Scabies/Lice		Yes	No
Are all medical reports as complete as possible (e.g., lab results and final diagnoses entered) in the UC Portal?		Yes	No
Have all medical documents (e.g., Initial Medical Exam form, immunization records, lab results) been uploaded to the UC Portal?		Yes	No

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to ensure that UAC are medically cleared for transfer within the ORR care provider network, excluding transfer to an influx care facility. Public reporting burden for this collection of information is estimated to average 0.08 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact [email protected].

Medical Checklist for Transfers, Rev. 09/05/2016

ORR UC/P-9A