Form S-16 Summary Notes Thirty Day Restrictive Placement Case Revi

OMB 0970‐#### [Valid through MM/DD/2020] 

SUMMARY NOTES: Thirty Day Restrictive Placement Case Review
DATE:
UAC Name:
A#:
D.O.B.:
Care Provider 1:
Placement Type:

Date and decision of UAC’s last 30 day restrictive placement case review or initial
placement at this facility, as applicable:
Is the 30 day review late, if so describe why (e.g. critical staff member unavailable;
holiday):
Summary of discussion:

1

If a TAR RTC, list name of “base” care provider first followed by the name of the RTC provider.

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 document the thirty day review for UAC in placed in a
restrictive setting. Public reporting burden for this collection of information is estimated to average 0.5 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, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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]. 

Summary of assessments/evidence:

Care Provider Recommendation (briefly describe):

Case Coordinator Recommendation (briefly describe):

FFS Decision (briefly describe):

Signature of Note Taker:

2