OMB 0970-#### [Valid
through MM/DD/2020]
Office of Refugee Resettlement
U.S. Department of Health and Human Service Medical Checklist for Influx Transfers, Rev. 12/05/2016
OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
MEDICAL CHECKLIST FOR INFLUX TRANSFERS
IDENTIFYING INFORMATION |
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UC’s Name:A#: |
Completed By (name and title): Date Completed: |
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INSTRUCTIONS |
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CHECKLIST |
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Meets Influx Transfer Criteria |
Does Not Meet Influx Transfer Criteria |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes NA1 |
No |
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Yes NA1 |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Yes NA1 |
No |
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Yes |
No |
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Yes |
No |
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Yes |
No |
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Clinician, please initial here: ______________ |
Yes |
No |
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Yes |
No |
1 NA: Question is not applicable (i.e., child is <15 years; pregnancy testing for males; flu vaccine is not seasonably available).
2 A lice, fever, and rash check will also be done within 24 hours of physical transfer, per the ORR Operations Guide, Section 1.2.10.
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 to an influx care facility. Public reporting burden for this collection of information is estimated to average 0.17 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 Influx Transfers, Rev. 12/05/2016
ORR UAC-P-9B
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Toby R. M. Biswas |
File Modified | 0000-00-00 |
File Created | 2021-01-13 |