Form M-8A Form M-8A UAC Case File Checklist

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Overview

Checklist
Services

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Sheet 1: Checklist

					OMB 0970-#### [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR Monitoring Team staff to document care provider compliance with ORR policies and procedures related to case file maintenance during biennial site visits. Public reporting burden for this collection of information is estimated to average 1.0 hour per response (plus an additional 6.0 hours if the site visit is performed by a contractor monitor), 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].
ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 09/28/2020)
Reviewer:		Date:			Release Category:
UAC Name:		A#:			Case Manager:
Nationality:		DOB:			Clinician:
Admitted Date:		Gender:			Transfer?
Date of Release:		Language(s):			Religion:
Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
		CF	Portal	Date	Notes
Admission Documents
Initial Intakes Assessment (within 24 hours)
Placement Authorization Form (signed by care provider within 24 hours.)
UAC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UAC annually)
Inventory of all Property and Cash (within 24 hours. Signed. Inventory should include clothing/cash kept by program and clothing/cash returned to UAC. Log should be updated as UAC receives additional property during his/her stay.)
Clothing and Supplies distributed to UAC
Other Admission Forms (insert below)
Orientation Documents (48 hours, translated into UAC language)
Acknowledgment of Orientation (Signed. Note in English indicating purpose of document. Should cover program rules and policies, grievance procedures, information on boundaries, abuse and neglect, and emergency and evacuation procedures.)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed
• 48 hours
• Refresher every 90 days
Documentation that UAC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UAC's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel)
Documentation that UAC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service providers and organizations that provide services to victims of sexual abuse and sexual harassment. (Signed. Information UAC received should include names, descriptions, addresses and phone numbers of national/local organizations.)
Other Orientation Forms (insert below)
Legal Information
Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13, 02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs, criminal/juvenile records.)
EOIR docs (Executive Office for Immigration)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UAC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours)
Documentation of Initial Medical Exam (unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider. Current Version - expiration: 05/31/22. Previous Version - expiration: 11/30/18)
Immunization Records
Record of Dental Exam(s) (Initial > 60, but < 90 days after admission. Effective 05/02/17 Portal: Initial Dental Exam, regardless of final outcome, should be recorded in the Health Tab; Recommendation every 6 months thereafter)
Prescriptions (including Prescription log.)
TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge. Current Version - expiration: 05/31/22. Previous Version - expiration: 11/30/18)
Communicable Diseases
Records of Office Visits/ER Visits/Hospital, Surgery (Medical information should be uploaded in respective section of Health tab; Mental health visits should be entered as Medical Complaint reports in the Health tab if the child is seen by a psychiatrist and/or prescribed a medication.)
Diagnosis List
Copies of Referrals for Medical Services
Medical or Mental Health Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable)
UAC Request for Emergency and Non-Emergency Health Care Services (Care providers must respond to non-emergency requests within 24 to 48 hours, excluding weekends and holidays.)
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
UAC Assessment (Effective: 12/16/16 - Within 5 days, should not be updated after day 5. Effective 3/23/16 - Medical Sections no longer need to be completed. If there is a significant condition/illness, program can write "refer to medical". Effective 12/06/16 - Programs are no longer required to complete the Sponsor Assessment sections for sponsors who are identified on 12/6/16 and going forward.)
UAC Case Review (Initial completed within 30 calendar days in care) (Effective 3/23/16 - Medical Sections no longer need to be completed. If there is a significant condition/illness, program can write "refer to medical". Effective 12/06/16 - Programs are no longer required to complete the Sponsor Assessment sections for sponsors who are identified on 12/6/16 forward.)
• Continuously updated until 30 calendar days after admission if required or relevant information that was unknown during the assessment is later received or additional information is obtained from the UAC or other sources (e.g. KYRs) OR
• Every 30 calendar days after admission opens NEW UAC Case Review OR
• Anytime there is a substantial change in the UAC's case information
Sponsor Assessment (Current version: 6/26/19; Effective: 12/6/16 - Within 5 days of identification of the primary sponsor. If information is not complete or collected by day 7, then CM should include a status update in UAC Case Review.)
• Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR
• Additional information is obtained from the sponsor, UAC, UAC’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity.
Individual Service Plan (Effective: 12/6/16 - Within 5 days.)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UAC's case information
Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UAC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UAC Assessment, UAC Case Review, and ISP; however, they are not responsible for providing the service and should not be written up if the LSP does not provide the service within the required timeframe.
Educational Services
Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UAC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)
Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity Log ("Recreation" - 1 hr outdoor large muscle (weather permitting) daily, 1 hr leisure daily; increases to 3 hr outdoor when school not in session. PE cannot count towards this requirement.) (Effective 3/20/20 - avoid community outings due to Covid-19.)
Phone Log (two 10 minute phone calls per week and list of approved contacts in the UAC case file)
Religious Services Log
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)
Clinical Services
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community meeting; should include acculturation and adaptation services such as developing social and interpersonal skills)
Incident Reports
SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version: 1/31/20) Previous Version: 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13, 02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)
Release Request (verify that the FFS has approved the release)
Discharge Notification
Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)
Log/checklist including all documents provided to UAC at discharge Checklist should include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
ORR National Call Center Flyers and Wallet Cards
CDC Covid-19 Fact Sheet and Symptoms Sheet (Effective: 3/13/20)
Discharge Checklist - Medical Records
Letter to Sponsor for UAC with latent TB or TB Exposure (ONLY for UAC who are diagnosed with LTBI or TB exposure)
Copy of Order of Removal (if applicable;)
Copy of Trafficking Eligibility Letter (if applicable)
Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form)
Post-Discharge
Safety & Well Being Follow-up Call (Effective: 3/14/16; all call attempts must be made within 7 days following the 30-day mark of the UAC’s release)
Health Follow-Up Call (Effective 4/6/20: Must follow up with sponsor for 14 days after release date; document if UAC is experiencing acute respiratory symptoms)
Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:
Trends/Patterns:
Covid-19 Update
Effective 3/20/20 delays in meeting deadlines due to Covid-19 related contraints must be documented

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Sheet 2: Services

Individual Clinical Services (pg)

Clinical Group Services (pg)

Community Group Meetings - "YCW Led Groups" (pg)

Case Management (pg)

Recreation - LMA (pg)

Activities - Leisure (pg)

Religious Services (pg)

Phone Log (pg)

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Comments

*Check that recreation activities are varied.