Form P-9B Medical Checklist for Influx Transfers

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
UC’s Name:       A#:      	Completed By (name and title):       Date Completed:      
INSTRUCTIONS
This checklist should be completed by a medical coordinator or other medical staff no later than 24 hours prior to the proposed transfer date. If “No” is checked for any of the below questions, do not transfer the child to an influx care facility. The completed checklist should be uploaded to the UC Portal 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. The person completing this form should initial the Care Provider Checklist for Transfers to Influx Care Facilities to indicate the child is medically cleared and vaccinated.
CHECKLIST
		Meets Influx Transfer Criteria	Does Not Meet Influx Transfer Criteria
Has the initial medical exam been completed?		Yes	No
Have results from all lab tests (e.g., STD tests) and medical consultations been received?		Yes	No
TB screening
Does the child have a negative PPD (<10 mm) or IGRA?		Yes	No
For 15-17 year olds, does the child have a normal chest X-ray?		Yes NA1	No
HIV screening Was the child tested for HIV? Check “No” if child opted out of HIV testing. If the child was tested, was the HIV test negative?		Yes Yes	No No
For females, was the pregnancy test negative?		Yes NA1	No
Did the child receive the following immunizations?
Tdap (tetanus, diphtheria, pertussis)		Yes	No
Hepatitis A		Yes	No
Hepatitis B		Yes	No
Varicella (chickenpox)		Yes	No
IPV (inactivated poliovirus vaccine)		Yes	No
MMR (measles, mumps, rubella)		Yes	No
MCV4 (meningococcal disease)		Yes	No
HPV (human papillomavirus)		Yes	No
Flu, when seasonably available (generally, September through June)		Yes NA1	No
Did the child receive all of the above immunizations more than 72 hours before the scheduled physical transfer?		Yes	No
Is the child currently clear of all contagious conditions, including scabies and lice?2		Yes	No
Have you confirmed the child has no known medical or dental issues requiring additional evaluation, treatment, or monitoring by a healthcare provider?		Yes	No
Has a clinician confirmed the child has no known mental health issues requiring additional evaluation, treatment, or monitoring? Clinician, please initial here: ______________		Yes	No
Has the following documentation been uploaded to the Files section of the Portal Health Tab: Initial Medical Exam form, Supplemental TB Screening form, lab results, immunization record, and chest x-ray reading (for 15-17 year olds)?		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