TAB J - Medical Checklist for Influx Transfers (Form P-9B)

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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
    1. Has the initial medical exam been completed?
 Yes
 No
    2. Have results from all lab tests (e.g., STD tests) and medical consultations been received?
 Yes
 No
    3. TB screening


    a. Does the child have a negative PPD (<10 mm) or IGRA?
 Yes
 No
    b. For 15-17 year olds, does the child have a normal chest X-ray?
 Yes    NA1
 No
    4. HIV screening
        a. Was the child tested for HIV? Check “No” if child opted out of HIV testing.
        b. If the child was tested, was the HIV test negative?

 Yes
 Yes

 No
 No
    5. For females, was the pregnancy test negative?
 Yes    NA1
 No
    6. Did the child receive the following immunizations?


        a. Tdap (tetanus, diphtheria, pertussis)
 Yes
 No
        b. Hepatitis A
 Yes
 No
        c. Hepatitis B
 Yes
 No
        d. Varicella (chickenpox)
 Yes
 No
        e. IPV (inactivated poliovirus vaccine)
 Yes
 No
        f. MMR (measles, mumps, rubella)
 Yes
 No
        g. MCV4 (meningococcal disease)
 Yes
 No
        h. HPV (human papillomavirus)
 Yes
 No
        i. Flu, when seasonably available (generally, September through June)
 Yes    NA1
 No
    7. Did the child receive all of the above immunizations more than 72 hours before the scheduled physical transfer?
 Yes
 No
    8. Is the child currently clear of all contagious conditions, including scabies and lice?2
 Yes
 No
    9. Have you confirmed the child has no known medical or dental issues requiring additional evaluation, treatment, or monitoring by a healthcare provider?
 Yes
 No
    10. Has a clinician confirmed the child has no known mental health issues requiring additional evaluation, treatment, or monitoring?
Clinician, please initial here: ______________
 Yes
 No
    11. 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