Form P-10A Transfer Request - UC Path Version

Transfer Request (Form P-10A)
Data Entry Window – Standard Transfer
• Influx Care Facility
• Long Term Foster Care
• LTFC – Community
Placements
• LTFC – Group Home
• Out-of-Network RTC
• Residential Treatment Center
• Secure
• Shelter
• Staff Secure
• Therapeutic Group Home
• Therapeutic Staff Secure
• Therapeutic Foster Care
• Emergency Intake Sites
• URM
• Other

• CM Initiated
• CC Review
• FFS Review
• Transfer Cancelled
• Completed

• Regular Transfer
• Influx Transfer

• To provide a less
restrictive setting
• To provide a more
restrictive setting
• Minor’s Medical
Health
• Minor’s Mental
Health
• Violent/Threatening
Behavior
• Disruptive Behavior
• Minor’s Safety
• Flight Risk
• Emergency Influx

• Charged with a crime
• Chargeable with a
crime
• Convicted of a crime
• Adjudicated
delinquent

• Unacceptably disruptive
to normal functioning of
a shelter care facility
• Are an escape risk
• Has displayed a pattern
of severity of behavior,
either prior to entering
ORR custody or while in
ORR care, that requires
an increase in
supervision by trained
staff.
• Non-violent criminal or
delinquent history not
warranting placement in
a secure care provider
facility
• Stepping down from a
secure facility

• Chargeable with a
delinquent act
• Violent or malicious acts
while in ORR care
• Unacceptably disruptive to
normal functioning of a
staff secure facility
• Self-disclosed violent
history prior to ORR
custody that requires
further assessment

• Have not shown reasonable
progress in the alleviate on mental
health symptoms after a significant
period of time in outpatient
treatment
• Demonstrate behavior that is the
result of underlying mental health
symptoms and/or diagnosis cannot
be managed in outpatient setting
• Require therapeutic-based
intensive supervision and/or
diagnosis that prevent independent
participation in the daily schedule
of activities
• Present a continued and real risk of
harm to self, others, or the
community despite the
implementation of short-term
interventions

• Yes
• No

• Pregnancy
• Injury
• Illness
• Diagnosed
Behavior/Illness with
no medications
• Diagnosed
Behavior/Illness with
medications
• Charge(s) Dropped

• Transfer
Recommended
• Transfer Not
Recommended

• Yes
• No

• Transfer
Recommended
• Transfer Not
Recommended
• ORR Required

• Influx Care Facility
• Long Term Foster Care
• LTFC – Community
Placements
• LTFC – Group Home
• Out-of-Network RTC
• Residential Treatment Center
• Secure
• Shelter
• Staff Secure
• Therapeutic Staff Secure
• Therapeutic Foster Care
• Emergency Intake Sites
• URM

• Yes
• No

• Influx Care Facility
• Long Term Foster Care
• LTFC – Community
Placements
• LTFC – Group Home
• Out-of-Network RTC
• Residential Treatment Center
• Secure
• Shelter
• Staff Secure
• Therapeutic Staff Secure
• Therapeutic Foster Care
• Emergency Intake Sites
• URM

• Yes
• No

• Transfer Approved
• Transfer Not Approved
• Transfer Remanded

• Change of Address
• Change of Venue

• Limited Juvenile
Detention Space
• UC has Special Need
• Other

Standard
system fields
that will not
be completed
and will be
removed in
future
development.

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 process recommendations and decisions for transfer of a UC within the ORR care provider network. Public reporting
burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case
coordinator (a total of 0.75 hours), 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-10A [Rev. MM/DD/YYYY]

Transfer Request Page – Details Tab

[PHOTO]

Standard
system fields
that will not
be completed
and will be
removed in
future
development.

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 process recommendations and decisions for transfer of a UC within
the ORR care provider network. Public reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case coordinator (a total of 0.75 hours),
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-10A [Rev. MM/DD/YYYY]

Transfer Request 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 process recommendations and decisions for transfer of a UC within
the ORR care provider network. Public reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case coordinator (a total of 0.75 hours),
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-10A [Rev. MM/DD/YYYY]

Entry Team Data Entry Window

Documents Data Entry Window

• Assistant Lead Case Manager
• Assistant Lead Clinician
• Attorney
• Case Coordinator
• Case Manager
• Clinician
• Contractor Field Specialist
• Direct Care Worker
• Direct Operations Coordinator
• Federal Field Specialist
• Federal Field Specialist Supervisor
• HS/PRS Primary Provider
• HS/PRS Subcontractors
• Lead Case Manager
• Lead Clinician
• Medical Coordinator
• Program Support Staff
• Read Only
• Supervisor
• Supervisory Case Coordinator

See table below.

•
•
See table below.

Yes
No

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

Background Check
Case Coordination and Discharge
Case Management

Compliance Document
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

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
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

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 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

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;
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

Transfer Request Page – Program Referrals 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 process recommendations and decisions for transfer of a UC within
the ORR care provider network. Public reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case coordinator (a total of 0.75 hours),
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-10A [Rev. MM/DD/YYYY]

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 process recommendations and decisions for transfer of a UC within
the ORR care provider network. Public reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case coordinator (a total of 0.75 hours),
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-10A [Rev. MM/DD/YYYY]