Form M-8C Home Study and Post-Release Services Case File Checklist

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Overview

HS Checklist
PRS Checklist
Coop Agree Signatures

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Sheet 1: HS 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 home study/post-release service 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 1.0 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 UACPolicy@acf.hhs.gov.
ORR/UCP Case File Checklist - Home Study Services (Updated: 04/22/2020)
Reviewer:		Date:
UAC Name:		A#:
Nationality:		DOB:
Date of Release:		Gender:
Date Accepted by Program:		Language(s):
Post Release Service Case Worker:		Religion:
		In Case File	Notes
	Home Study Services
Referral acceptance (did the care provider contact the care provider within 24 hours) (reviews Release Request and staffs the case within 2 business days) (Policy, Revised 1/9/17) (UAC MAP Posted: 4/20/18)
Referral Acceptance (did the care provider contact the sponsor within 48 hours) (Policy, Revised 1/9/17) (UAC MAP Posted: 4/20/18)
Home Study Report (ORR template)(submitted to ORR within 10 business days of accepting referral OR documented ORR approval of extension) (report should be uploaded to portal) (Policy, Revised 1/9/17) (UAC MAP Posted: 4/20/18)
Documentation of household member interviews or all attempts to contact the household member (Policy, Revised 1/9/17)
Documentation of Interview with UAC (In-person, Skype, or phone) (Policy, Revised 1/9/17)
Quality of case notes (assess for recommendation - do notes document details of child interviews, home visit, contact with sponsor, home study conducted as a psycho-educational process, resources identified for UAC needs)
Documentation of in-person home visit (Policy, Revised 1/9/17)
Assessment (quality, did recommendation include adequate support) (Policy, Revised 1/9/17) (assess for recommendation: PO suggests that the assessment is signed and dated by supervisor)

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Sheet 2: PRS Checklist

ORR/UCP Case File Checklist - Post Release Services (Updated: 04/22/2020)
Reviewer:		Date:
UAC Name:		A#:
Nationality:		DOB:
Date of Release:		Gender:
Date Accepted by Program:		Language(s):
Post Release Service Case Worker:		Religion:
		In Case File	Notes
Please note that revised and effective dates reflect ORR Guide policy. When citing the Cooperative Agreement, please use the date it was signed by the provider. This information is listed on the sheet entitled Coop Agree Signatures*
PRS Opening/Ongoing Services
Documentation that PRS provider initiated services within two days of accepting referral (Policy, Revised 9/5/18)
Documentation that PRS provider began services within two days of release from ORR custody (For TVPRA Cases only) (Policy, Revised 9/5/18)
PRS continued in child's new residence (if applicable) (Policy, Posted 9/11/17)
Documentation of all communication with PRS provider and sponsor and/or child (does PRS worker begin identifying individual needs) (Policy, Effective 10/1/16)
Documentation that any issues surrounding safety and well-being are elevated to appropriate investigative agencies (ex. CPS, police) (Policy, Effective 10/1/16)
PRS Level One Services
Documentation of in-home engagements (Policy, Posted 9/11/17)
Documentation of assessing the needs and assisting children and their sponsors in accessing community services (with focus on accessing the post release service areas listed in policy and the 'documentation of needs section') (Policy, Posted 9/11/17)
Documentation of a referral to Level Two (2) Services, if necessary (Policy, Posted 9/11/17)
PRS Level Two Services
Documentation of regularly scheduled home visits (at least once a month) (Policy, Posted 9/11/17)
Documentation of on-going needs assessments of the child (Policy, Posted 9/11/17)
Documentation of comprehensive case management (Policy, Posted 9/11/17)
Documentation of access to therapeutic support (Policy, Posted 9/11/17)
PRS TVPRA Services
Case is active for more than one year, assessed for no major concerns and documentation of monthly check-ins (Policy, Revised 9/5/18)
Documentation of Needs
**Note: not all of the needs listed will apply to all UACs and sponsors. Services provided are based upon the sponsor and the UAC's individual needs**
Documentation of PRS providers assisting UAC and sponsor in accessing the following services, based upon individual needs (Policy, Posted 9/11/17) (PRS providers must adjust services in response to the changing needs of the child and sponsor)
Placement Stability and Safety (Policy, Posted 9/11/17)
Guardianship (Policy, Posted 9/11/17)
Immigration Proceedings (Policy, Posted 9/11/17)
Legal Services (Policy, Posted 9/11/17)
Education (Policy, Posted 9/11/17)
Medical Services (Policy, Posted 9/11/17)
Individual Mental Health Services (Policy, Posted 9/11/17)
Family Stabilization/Counseling (Policy, Posted 9/11/17)
Substance Abuse (Policy, Posted 9/11/17)
Gang Prevention (Policy, Posted 9/11/17)
Other Services (Policy, Posted 9/11/17)
Quality of notes (assess for recommendation -- Do notes detail services, resources, needs, and changes in needs? How is a need addressed? Are details about resources and referrals for services included in notes?)
PRS Required Documents to Submit to ORR
Monthly Follow-Up Reports (includes outcomes of all service areas accessed by the child and/or sponsor) (Policy, Posted 9/11/17)
Notifications of Concerns (as necessary) (includes any immediate dangers regarding a child's safety and well-being) (Policy, Posted 9/11/17)
Case Closure report (includes outcomes of all service areas accessed by the child and/or sponsor) (Policy, Posted 9/11/17)
Documentation of why services terminated (after 90 days; child turned 18 years old; or assessed services no longer needed) (Policy, Revised 9/5/18)
Documentation of why services terminated (TVPRA only: granted voluntary departure; received order of removal; obtained immigration status; or child turned 18 years old) (Policy, Revised 9/5/18)

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Sheet 3: Coop Agree Signatures

Program	Date Cooperative Agreement Signed	Signed By
SWK Program	7/2/2018	Juan Sanchez, President and CEO
Lutheran Immigration and Refugee Service, Inc.	6/19/2019	Kay Bellor, Vice President of Programs
Heartland Human Services	6/8/2018	David Sinski, Executive Director
United States Conference of Catholic Bishops	9/7/2018	William Canny, Executive Director
U.S. Committee For Refugees and Immigrants	5/17/2018	Eskinder Negash, President and CEO
Youth for Tomorrow	5/23/2018	Gregory Jones?, CEO
Morrison Child and Family Services	5/21/2018	Drew Henrie-McWilliams, CEO
BCFS Health and Human Services	5/17/2018	Sonya Thompson, Executive Director
Florence Crittenton Services of Orange County, Inc.	5/16/2018	Joyce Capelle, President and CEO
The Children's Village, Inc.	5/16/2018	Regis McDonald, Senior Vice President for Programs and Policy
Mercyfirst	5/17/2018	Jacqueline McKelvey
Signed PDF copies of the Cooperative Agreements can be found at this location on the S-Drive:
S Drive Link to Signed Cooperative Agreement PDFs 2018