Form P-12 Program Entity - UC Path

Program Entity (Form P-12)
Data Entry Window
• Active
• Inactive
• Draft
• Influx Care Facility
• Long Term Foster Care
• LTFC – Community
Placements
• LTFC – Group Home
• Residential Treatment Center
• Secure
• Shelter
• Staff Secure
• Therapeutic Group Home
• Therapeutic Staff Secure
• Therapeutic Foster Care
• Emergency Intake Sites
• Other

List of all countries

•1
•2
•3
•4
•5
•6
•7
•8
•9
• 10
• Arizona
• Central Texas
• Houston/El Paso
• Mid-Atlantic
• Mid-West
• North East
• Rio Grande Valley
• South East
• Special Population
• West Coast
• Month 1: Weeks 1 to 4
• Month 2: Weeks 5 o 8
• Month 3: Weeks 9 to
13
• Month 4: Weeks 14 to
17
• Month 5: Weeks 18 to
22
• Month 6: Weeks 23 to
27
• Month 7: Weeks 28 to
31
• Month 8: Weeks 32 to
35
• Month 9: Weeks 36 to
40

• Yes
• No

List of all 50 U.S. states and
the District of Columbia

• Yes
• No
• Yes
• No

• Yes
• No

List of licensing entities
for all states in which
ORR operates care
provider programs
List of all license types
offered by the licensing
entities available under
the Licensing Entity
Field, as applicable to
ORR care provider
programs

• Yes
• No

• Yes
• No

• Imminent risk of harm to or
safety of UC
• Imminent risk of harm to or
safety of staff
• Law enforcement agency
recommendations to cease
new referrals
• Identified risk is not related to
one staff or incident, and
cannot be corrected by the
corrective action
• Active CPS licensing
investigation involving staff, UC
or both
• Grantee repeated noncompliance with ORR policies
and procedures which impacts
service to UC
• Shortage of staff
• Staff related incident
• Consistent pattern of UC AWOL
• Affected by natural
disasters/evacuation
• Power outage
• Fire incident
• Isolation/Medical Concerns
• Request by the facility
• Other (provide details)

OMB 0970-0554 [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 to track
certain information related to its care provider programs, such as location, contact information, bed capacity, state licensure, grant information, monitoring, and
program census. 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). 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].
P-12 [Rev. MM/DD/YYYY]

Program Entity Page – Details Tab

OMB 0970-0554 [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 to track certain information related to its care provider programs, such as location, contact information, bed
capacity, state licensure, grant information, monitoring, and program census. 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). 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].
P-12 [Rev. MM/DD/YYYY]

Program Entity Page – Census Page

OMB 0970-0554 [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 to track certain information related to its care provider programs, such as location,
contact information, bed capacity, state licensure, grant information, monitoring, and program census. 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). 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].
P-12 [Rev. MM/DD/YYYY]

Program Entity Page – Related Tab

OMB 0970-0554 [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 to track certain information related to its care provider programs, such as location,
contact information, bed capacity, state licensure, grant information, monitoring, and program census. 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). 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].
P-12 [Rev. MM/DD/YYYY]

Funded Capacity Manager

Entity Team Data Entry Window

• Read Only
• Read/Write
• Read Only
• Read/Write
• No Access
• Read Only
• Read/Write
• No Access

Information Data Entry Window

This is a global picklist used across
multiple forms that contains all
roles. Appearance of a role on this
list does not mean that role will be
granted access to this form.

• Assistant Program Director
• Attorney
• Case Coordinator
• Case Manager
• Child Advocate Contact
• Clinician
• Contractor Field Specialist
• DHUC Medical Team Member
• DHUC Quality Assurance Specialist
• Direct Operations Coordinator
• DOJ/FBI
• Federal Field Specialist
• HHS OIG
• HS/PRS Primary Providers
• ICE FOJC
• Influx POC
• Intakes Backup Contact
• Intakes Contact
• Lead Case Manager
• Lead Clinician
• Legal Service Provider
• LNO
• Medical Coordinator
• Medical Service Director
• On-site Health Care Provider
• ORR Compliance Team
• Program Director
• Program Support Center
• Project Officer
• PSA Compliance Manager
• PSA Program Specialist
• PSA Team
• Regional Director
• Registered Nurse
• Senior Advisor for Child Well-Being & Safety
• Shift Supervisor
• Supervisory Case Coordinator
• Supervisory FFS
• Supervisory Project Officer
• Temporary
• VOLAG User
• Program Support Staff
See table below.

•
•

Yes
No

See table below.

Dropdown options for “Record Type” and corresponding options for “Document Type”
Record Type
Proof of Relationship

Document Type
Birth Certificate – UC; Baptismal Certificate; Birth Certificate – Sponsor; Birth Certificate – Other; Consulate
Written Affirmation of Relationship; Verified by Government Agency/Consulate; Court Order – Adoption; Court
Order – Guardianship; Court Order – Other; Government Issued Photo ID; Government Issued Ration Card;
Hospital Record; Interview Notes; Land Deeds – Sponsor and UC’s Family; Letter of Designation for Care of a
Minor; Marriage Certificate; Passport (including stamps); Photographs; Remittance Receipts; School
Record/Diploma; Social Media Posts; Genogram; Other

Background Check
Case Coordination and Discharge
Case Management

FBI Criminal History and FBI Name Check
Verification of Release; Release Request; Discharge Notification; ORR Notice to ICE; and Notice of Transfer to ICE
Verification of Release; Release Request; Discharge Notification; ORR Notice to ICE; New Placement Orientation;
Safety Plan; Other; Medical Checklist; Transfer; Admission Assessment; Influx Transfer Facility Checklist; and
LTFC Memo

Compliance Document

Other; ORR Closed Corrective Action; ORR Closed Monitoring Report; ORR Site Visit Report; Program Licensing
Investigation; and PSA Audit
Privacy 101; ROB; and Cybersecurity
Other, Initial Education Intake Assessment; ESL Assessment; Progress Report Card; and Educational
Reassessment Report
FRP 2 Authorization for Release of Information; FRP 3 Family Reunification Application; FRP 9 Letter of
Designation for Care of a Minor; and FRP 10 Sponsor Declaration
Other; Facility Intake List; Program Brief; Program Lease; Signed Cooperative Agreement; State Licensure; Fire
Inspection; Emergency/Evacuation Plan; and Facility Floor Plan
Addendum; Other Supporting Documents; and Post Release Assessment Report
Public Health Investigation Form; Hospital Discharge Instructions; Hospital Discharge Summary; Image Study
Reading (TB); Image Study Reading (Non-TB); Immunization Record; Initial Medical Exam Form; Initial Dental
Exam Form; Lab Results; Medications; Health Evaluation Form; Office Notes; Specialist Notes; Supplemental TB
Screening Form; and Other Health Document
All “Document Type” options available under other Record Types are available for this Record Type
Birth Certificate – UC; Court Order (Flores Bond); Court Order (Other); Court Order (Removal); Court Order (VD);
Decision (Administrative Review); Decision (Appeal of ORR Decision); Decision (Flores Bond Letter); Decision
(Specific Consent); DHS Document (I-213); DHS Document (NTA); DHS Document (Other); Form (Attorney of
Record); Form (Authorization for Release of Information); Form (Change of Venue); Form (Flores Bond Hearing
Motion); Form (Legal Resource Guide Part II – Admission); Form (Legal Resource Guide Part III – Release); Form
(Notice of Placement); Form (Specific Consent); Other Legal Document; OTIP Eligibility Letter; OTIP Interim
Assistance Letter; Placement Identification Document; Records (Court); Records (Criminal/Delinquency Records);
and Post Legal Status Plan
DHS Docs and Medical Checklist
Clinical Notes; Progress Notes; Discharge Summary; Psychiatric Evaluation Report; Psychological Evaluation
Report; RTC Recommendation Letter; Developmental Assessment Report; and Other Mental Health Document
Behavior Management Plan; Care Provider Policies and Procedures; Community Partnerships/Services; Cost of
Care; Education Documents; Emergency and Evacuation Plan; Fire and Safety Code Permits/Reports; Food
Services; Foster Home Safety Checklist; Foster Parent Agreement; Foster Parent Files; Foster Parent Orientation
Manual; Foster Parent Trainings; Full Staff List; Geographic Areas Served; Health/Sanitation Inspection Reports;
Independent Living Resources; List of Current Foster Parents; List of Home Study Cases; Map of Facility;
Memorandum of Understanding; Monitoring Schedule; Monitoring Tools and Instruments; Monitoring Visit
Reports; Mosquito Control Inspection; Organizational Chart; Quality Assurance Resources; Respite and Retention
Procedures; Site Visit Guide; Staff Trainings; Staffing Plan; State Licensing/CPS; UC Case Files; UC Orientation
Packet; UC with G-28s; and Vehicle Inspections
Other; Grantee Daily Schedule; Internal SOPs; Staff Training Curriculum; Educational Curriculum; Vocational
Curriculum; Food Menu; UC Handbook/Orientation; Prevention of Sexual Abuse/Harassment SOPs; and
Organizational Chart
DocGen; Placement Authorization; Medical Authorization; Notice of Placement; UC Assessments; New
Placement Orientation; Other; and Manifest
Policy Memo; Field Guidance; Interim Guidance; Form or Related Material; Frequently Asked Questions;
Procedure Manual; Other Guidance; Resource Material; and Training
Other
Current Lease or Mortgage Statement; Notarized Letter from Landlord; Utility Bill, Bank Statement; Payroll
Check Stub; Official Mail; Other Similar Document; and Letter/Code
Proof of Financial Stability
US Passport; US Passport Card; Foreign Passport; Permanent Resident Card; Alien Registration Receipt Card;
Employment Authorization Document; US Driver’s License or Identification Card; US Certificate of Naturalization;
US Military Identification Card; Birth Certificate; Court Order for Name Change; Foreign National Identification
Card; Consular Passport Renewal Receipt; Foreign Driver’s License; Foreign Voter Registration Card; Canadian
Border Crossing Card; Mexican Border Crossing Card; Refugee Travel Documents; Other Similar Government
Document; and Marriage Certificate
US Passport; Valid Visa; Legal Permanent Resident Card; Notice to Appear; Other Federal Government Document
Providing Immigration Status; US Birth Certificate; US Naturalization Papers; Court Order; and Other
Government Issued Document Proving US Citizenship
Birth Certificate – UC; Baptismal Certificate; DocGen; FRP 2 Authorization for Release of Information; FRP 3
Family Reunification Application; FRP 9 Letter of Designation for Care of a Minor; and FRP 10 Sponsor
Declaration; US Passport; US Passport Card; Foreign Passport; Permanent Resident Card; Alien Registration Card
Receipt; Employment Authorization Document; US Driver’s License or Identification Card; US Certificate of
Naturalization; US Military Identification Card; Birth Certificate; Court Order for Name Change; Foreign National
Identification Card; Consular Passport Renewal Receipt; Foreign Driver’s License; Foreign Voter Registration
Card; Canadian Border Crossing Card; Mexican Border Crossing Card; Refugee Travel Documents; Valid Visa;
Legal Permanent Resident Card; Notice to Appear; Other Federal Government Document Providing Immigration
Status; US Birth Certificate; US Naturalization Papers; Court Order; and Other Government Issued Document
Proving US Citizenship; Birth Certificate – Sponsor; Birth Certificate – Other; Consulate Written Affirmation of
Relationship; Verified by Government Agency/Consulate; Court Order – Adoption; Court Order – Guardianship;

Compliance Forms
Education
FRP Forms
Facility Document
HS/PRS Document
Health Documentation

Legacy Document
Legal Document

Medical Document
Mental Health Documentation
Monitoring Visit

Operational Document
Other
Policy Guidance Documents
Profile Picture
Proof of Address
Proof of Financial Stability
Proof of Identity

Proof of Immigration Status or U.S. Citizenship
Referral Documents

Release Request
SIR/PLE Report Document
Self-Disclosed Criminal History
Sponsor Assessment

Court Order – Other; Death Certificate; Family Session Case Note; Government Issued Photo ID; Government
Issued Ration Card; Hospital Record; Interview Notes; Land Deeds – Sponsor and UC’s Family; Letter of
Designation for Care of a Minor; Marriage Certificate; Passport (including stamps); Photographs; Remittance
Receipts; School Record/Diploma; Social Media Posts; Genogram; Current Lease or Mortgage Statement;
Notarized Letter from Landlord; Utility Bill, Bank Statement; Payroll Check Stub; Official Mail; Other Similar
Document; Letter/Code; Proof of Financial Stability; Self-Disclosed Criminal History; Verification of Release;
Release Request; Discharge Notification; ORR Notice to ICE; Referral Documents; and Other
Best Interest Recommendation Letter; R-4 Release Request; ORR Denial Letter; Parent Denial Letter; Program
Acceptance Letter; Recommendation to Deny Release; Referral Services COO; Safety Plan; Travel Document;
Travel Itinerary; and Other
Police Report; State Licensing Documentation; Fraud Documentation; CPS Documentation; Significant Incident
Report; PLE Report; Other; DOJ/FBI Documentations; and HHS OIG Documentation
Self-Disclosed Criminal History
Initial and Final

Beds Data Entry Window

• Delivered
• Undelivered
• Male
• Female

• Expectant mother bed
assignment
• Licensing issue
• Medical
isolation/quarantine
• Mom/baby bed
assignment
• Other
• Other medical
concerns/reasonable
accommodations
• Power Outage
• Protest
• Repairs needed
• Staff shortage
• Transgender bed
assignment
• UC behavioral
concerns/1:1 supervision
required
• Unavailability of foster
parent
• Weather event or natural
disaster

• Available
• Unavailable
• On-Hold
• Occupied
• Reserve
• Warm