| OMB 0970-0564 [valid through MM/DD/2026] |
| THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR contractor monitors to document care provider compliance with ORR policies and procedures related to case file maintenance during quarterly site visits. Public reporting burden for this collection of information is estimated to average 1 hour per response for the care provider and 6 hours per response for the 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]. |
| Unlicensed Facility UC Case File Checklist |
| UPDATED UC CASE FILE CHECKLIST: DIRECTIONS |
| This revised case file checklist uses formulas to provide summary information in the "UC_CL_Summary" tab, based on each case file that you review (i.e., the tabs titled "UC_CL_#"). A few important things to know across the "UC_CL_Summary" and "UC_CL_#" tabs: |
| • Each individual case has its own tab (i.e., "UC_CL_#") within this overall Excel spreadsheet. |
| • Instead of checkboxes, the rows of the case file checklist now have a dropdown menu. The dropdown options and loose definitions are: |
| • Present, compliant: The document is in the case file/UC Portal, and there are no issues with it. The document was completed on time, is fully filled out, etc. |
| • Present, noncompliant: The document is in the case file/UC Portal, but there is at least one issue with it. For example, it was completed late, or it is missing a signature. |
| • Not present: The document is supposed to be in the case file/UC Portal, but is missing. |
| • N/A: The document is not applicable for this case. For example, the document is supposed to be completed on a UC's 30th day in care, but the UC was only in care for 15 days. |
| • Not reviewed: You have not yet reviewed the case file/portal to see if the document is present and compliant. NOTE: This is the default choice selected for each cell with the drop-down menu; please update the response, as necessary, per cell. |
| • Use your professional judgement when deciding how to categorize each file. |
| • We recognize that these categories don't work perfectly for every row. Do your best when this is the case, and just ensure you remain consistent across each file you review. |
| • In these tabs, some cells are unlocked, which enables you to input information / data. Other cells, in contrast, are locked and are not editable. For both unlocked and locked cells, you can modify the width/height/area of a cell by pulling the row/column line to the desired location. |
| To ensure the Excel file continues to function correctly, do not: |
| • Change the name of any tabs in this file |
| • Add or delete any rows or columns |
| In the "UC Services" tab, be aware of the following points: |
| • This tab is optional to complete. |
| • Per UC case file that you review, input each service that a UC received/attended, all in this tab. For example: |
| • If UC #1 received/attended 10 Individual Clinical services, you'd input information / data into the first 10 rows and select Individual Clinical Service from the Service column’s drop-down menu. |
| • If UC #2 received/attended 12 services for Case Management, you'd input information / data into the next 12 rows and select Case Management from the Service column’s drop-down menu. |
| • If UC #3 received/attended 8 services (2 for Individual Clinical Services and 6 for Case Management), you'd do the following: |
| • Input information / data for the two individual clinical services into the next two rows and select Individual Clinical Service from the Service column’s drop-down menu. |
| • Input information / data for the six case management services into the next six rows and select Case Management from the Service column’s drop-down menu. |
| • Per UC case file that you review, input the number that corresponds to the tab of the UC case file in each row (or service) in the first column of this tab. For example, since UC #1 above received 10 services, you'd input "1" into the first column of this tab for each of the 10 rows for UC #1. |
| • In this tab, you will only be able to input information / data into, as well as expand, cells that require those inputs. For other cells (and columns/rows), you will not be able to edit (or insert) them at all. |
| The UC Case File Checklist has items that are personally identifiable information (PII)* and sensitive PII**. To be compliant with HHS Privacy Policies, please note the following requirements: |
| • E-mailing UC Case File Checklists (draft and final versions) with only PII |
| • Enable password-protection on the checklists. |
| • E-mailing UC Case File Checklists (draft and final versions) with sensitive PII |
| • Enable password-protection on the checklists and encrypt the e-mails. |
| • UC Case File Checklists (draft and final versions) with sensitive PII on the S drive |
| • Enable password-protection on the checklists (and any accompanying files with sensitive PII) at all times. |
| • UC Case File Checklists (draft and final versions) on MS Teams |
| • UC Case File Checklists on MS Teams with sensitive PII: |
| • First create a private Team space to limit staff who can access the checklist and then encrypt the file and then work in the file accordingly.* Try to limit sensitive PII found in the checklist on MS Teams. When you move the checklists to the S drive, ensure the checklists have encryption/password-protection enabled. * Note: file encryption on MS Teams might restrict multiple team members working on the file at once. |
| • UC Case File Checklists on MS Teams without sensitive PII: |
| • First create a private Team space to limit staff who can access the checklist and then work in the checklists as you normally would. You might have corresponding file(s) with the sensitive PII noted for reference as you work on the checklists; please also password-protect any corresponding files. When you are ready to save the final version of the checklists to the S drive, include the sensitive PII in the checklists and ensure the checklists have encryption/password-protection enabled. |
| * PII is “information that can be used to distinguish or trace an individual’s identity, either alone or when combined with other information that is linked or linkable to a specific individual.” Examples of PII include name, phone number, email address, and Social Security number, as well as information that is personally identifiable when linked with other information such as, in some cases, a job title in combination with place of employment. |
| ** Sensitive PII includes (but is not limited to) the following examples: |
| • A# (by itself or in combination with other PII) |
| • Date of birth in combination with other identifiable information (such as name, passport number, phone number, etc.) |
| • Citizenship or immigration status in combination with other identifiable information (such as name, passport number, phone number, etc.) |
| • Passport number in combination with other identifiable information (such as name, phone number, etc.) |
| • Ethnic or religious affiliation in combination with other identifiable information (such as name, passport number, phone number, etc.) |
| • Sexual orientation in combination with other identifiable information (such as name, passport number, phone number, etc.) |
| • Criminal history in combination with other identifiable information (such as name, passport number, phone number, etc.) |
| • Current or previous personal contact information (such as home address, personal phone number, personal e-mail address, etc.) in combination with other identifiable information (such as name, passport number, etc.) |
| Contact the Monitoring 2.0 Team if you: |
| • Have any issues using the checklist |
| • Have any recommendations for additional changes |
| • Need additional tabs added to the file so that you can review more than 10 files from the same monitoring visit. |
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| ORR/UCP Master Case File Checklist - OPEN/CLOSED (Updated: 2/17/23) |
|||||
| Reviewer: | Date: | Release Category: | |||
| UC 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 | |||||
| Hard Case File | Portal | Date | Notes | ||
| Admission Documents | |||||
| Initial Intakes Assessment (within 24 hours) | Not reviewed | Not reviewed | |||
| Placement Authorization Form (signed by care provider within 24 hours.) | Not reviewed | Not reviewed | |||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | Not reviewed | Not reviewed | |||
| Inventory of all Property and Cash (Signed by UC within 2 hours of admission. Inventory should include clothing, cash, valuables, and personal items the UC had upon admission . | Not reviewed | ||||
| Clothing and Supplies distributed to UC (Should include items given to the UC at the time of admission, as well as any items given to the UC throughout their length of stay) | Not reviewed | ||||
| Other Admission Forms (insert below) | Not reviewed | ||||
| Orientation Documents (48 hours, translated into UC language) | |||||
| Acknowledgment that UC received Orientation in his or her language (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.) | Not reviewed | ||||
| Documentation that an Orientation related to the “Garza v. Azar” court ruling has been completed, if applicable (48 hours, translated into UC language) | Not reviewed | ||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | |||||
| • 48 hours | Not reviewed | ||||
| • Refresher every 90 days | Not reviewed | ||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC 's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | Not reviewed | ||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | Not reviewed | ||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | Not reviewed | ||||
| Other Orientation Forms (insert below) | Not reviewed | ||||
| Legal Information | |||||
| Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours of admission. 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.) |
Not reviewed | Not reviewed | |||
| Birth Certificate | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| EOIR docs (Executive Office for Immigration Review) | Not reviewed | ||||
| Court Documents/Criminal History Records (if applicable) | Not reviewed | ||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | Not reviewed | ||||
| Authorization for Release of Records (if applicable) | Not reviewed | ||||
| Medical Documents | |||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours of admission) | Not reviewed | Not reviewed | |||
| Documentation of Initial Medical Exam (Within 48 hours of admission, unless the minor obtained a medical exam within one calendar year while under the care of another ORR-funded care provider, and there is documentation of receiving the medical exam; Current Version - expiration: 12/31/23. Previous Version - expiration: 5/31/22, 11/30/18) *As a reminder, completion of the Initial Medical Exam form is mandatory by the healthcare provider (HCP) unless the HCP provider is employed by the grantee and enters the data directly into the UC Portal/Path during the evaluation. | Not reviewed | Not reviewed | |||
| Immunization Records | Not reviewed | Not reviewed | |||
| Dental Exam Form: Record of dental exam(s) (Initial exam must be within 60-90 days of admission into ORR care. Effective 7/10/22. Current Version – expiration 12/31/23); Dental Exam Form must be completed by the dentist by the conclusion of all dental visits and returned to the care provider program for review and etnry into the UC Portal Health tab. | Not reviewed | Not reviewed | |||
| Prescriptions (including Medication Administration Record/log) | Not reviewed | ||||
| Supplemental TB Screening Form: Must be completed by HCP or care provider program staff. TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the case file at discharge) Current Version - expiration: 12/31/23 05/31/22. Previous Version - expiration: 5/31/22; 11/30/18) | Not reviewed | ||||
| Communicable Diseases | Not reviewed | Not reviewed | |||
| 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.) | Not reviewed | Not reviewed | |||
| Diagnosis List | Not reviewed | ||||
| Copies of Referrals for Medical Services | Not reviewed | ||||
| Medical Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | Not reviewed | ||||
| Mental Health Records (within 48 hours of a mental health visit, the health assessment form needs to be completed and information needs to be entered into the UC Portal. DHUC guidance issued July 12, 2022). | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
Not reviewed | ||||
| Assessments | |||||
| Risk Assessment | |||||
| • Within 72 hours | Not reviewed | Not reviewed | |||
| • Updated every 30 days | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| UC 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.) | Not reviewed | Not reviewed | |||
| • Initial case review 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 UC or other sources (e.g. KYRs) OR | Not reviewed | Not reviewed | |||
| • Subsequently every 30 calendar days after admission opens NEW UC Case Review OR | Not reviewed | Not reviewed | |||
| • Anytime there is a substantial change in the UC 's case information | Not reviewed | Not reviewed | |||
| Sponsor Assessment (Current version: 5/10/22; Effective: 12/6/16 - Must be initiated within 5 days of identification of the primary sponsor). Previous version(s): 7/14/21, 6/26/19 |
Not reviewed | Not reviewed | |||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
Not reviewed | Not reviewed | |||
| • Additional information is obtained from the sponsor, UC , UC ’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
Not reviewed | Not reviewed | |||
| Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of admission) | Not reviewed | Not reviewed | |||
| Individual Service Plan Update | |||||
| • Every 30 days in care OR | Not reviewed | Not reviewed | |||
| • Any time there is a substantive change in UC 's case information | Not reviewed | Not reviewed | |||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | Not reviewed | Not reviewed | |||
| Educational Services | |||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | Not reviewed | Not reviewed | |||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | Not reviewed | Not reviewed | |||
| Class Attendance (Effective 1/2/19) | Not reviewed | Not reviewed | |||
| Case Management | |||||
| Case Manager Progress Notes (1 per week) | Not reviewed | ||||
| Quality of Case Manager Notes | Not reviewed | ||||
| Logs: | |||||
| Recreation/Leisure Activity Plan/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.) | Not reviewed | ||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | Not reviewed | ||||
| Religious Services Log | Not reviewed | ||||
| Visitor Log | Not reviewed | Not reviewed | |||
| Stipend Log (Only if stipends are mandated by state licensing) | Not reviewed | ||||
| Clinical Services | |||||
| Disclosure Notice (completed by a clinician within 5 days of admission and prior to the UC Assessment) | Not reviewed | ||||
| Clinical Progress Notes - Individual Counseling (1 per week) | Not reviewed | ||||
| Quality of Clinical Notes | Not reviewed | ||||
| Progress Notes Related to Mental Health Services (if applicable) | Not reviewed | ||||
| 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) | Not reviewed | ||||
| Incident Reports | |||||
| SIRS (time sensitive) | Not reviewed | Not reviewed | |||
| Internal Incidents | Not reviewed | ||||
| Grievances | Not reviewed | ||||
| Discharge | |||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective: 12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19 | Not reviewed | ||||
| Log of Property returned/disbursedat Discharge | Not reviewed | ||||
| 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.) | Not reviewed | ||||
| Release Request (verify that the FFS has approved the release) | Not reviewed | ||||
| Discharge Notification | Not reviewed | ||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | Not reviewed | Not reviewed | |||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | Not reviewed | ||||
| Sponsor Care Agreement | Not reviewed | ||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | Not reviewed | ||||
| Educational assessments and records | Not reviewed | ||||
| Change of Venue/Change of Address forms | Not reviewed | ||||
| Post-release safety plan (if applicable) | Not reviewed | ||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | Not reviewed | ||||
| Covid-19 Discharge Letter for Sponsors (English and Spanish versions. Current Version: 1/24/23; Effective 1/28/22.) Previous Version: 1/28/21, 6/10/21 |
Not reviewed | ||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
Not reviewed | ||||
| Post-18 Plan (if applicable) | Not reviewed | ||||
| Discharge Checklist - Medical Records | Not reviewed | ||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | Not reviewed | ||||
| Copy of Order of Removal (if applicable) | Not reviewed | ||||
| Copy of Trafficking Eligibility Letter (if applicable) | Not reviewed | ||||
| Transfer to another ORR Care Provider (Non-Influx Site) | |||||
| All Family Reunification Forms and Supporting Documentation | Not reviewed | Not reviewed | |||
| Care Provider Family Reunification Checklist | Not reviewed | Not reviewed | |||
| Medical Checklist for Transfers | Not reviewed | Not reviewed | |||
| Transfer Request and Tracking Form | Not reviewed | Not reviewed | |||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | Not reviewed | Not reviewed | |||
| 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 UC ’s release) | Not reviewed | ||||
| Health Follow-Up Call (Revised June 4, 2021; Effective 4/6/20: Must follow up with sponsor once between days 7-10 following UC’s release. Case managers should notify DHUC if the sponsor reports the UC tested positive for COVID-19 within 10 days of discharge from ORR custody. The one-time check does not need to be completed for UC who tested positive in ORR care and recovered from COVID-19 within the past 90 days, or for UC who are fully vaccinated at the time of discharge. | Not reviewed | ||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | |||||
| Comments: | |||||
| Trends/Patterns: |
|||||
| Covid-19 Update | |||||
| Summary Data | ||||||||||||
| Case File # Reviewed | # Case File: Present, compliant | # Case File: Present, noncompliant | # Case File: Not present | # Case File: N/A | Portal # Reviewed | # Portal: Present, compliant | # Portal: Present, noncompliant | # Portal: Not present | # Portal: N/A | Notes | ||
| Admission Documents | ||||||||||||
| Initial Intakes Assessment (within 24 hours) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Placement Authorization Form (signed by care provider within 24 hours.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other UC annually) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Inventory of all Property and Cash (within 24 hours. Signed. Inventory should include clothing/cash kept by program and clothing/cash returned to UC. Log should be updated as UC receives additional property during his/her stay.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Clothing and Supplies distributed to UC | 0 | 0 | 0 | 0 | 0 | |||||||
| Other Admission Forms (insert below) | 0 | 0 | 0 | 0 | 0 | |||||||
| Orientation Documents (48 hours, translated into UC language) | ||||||||||||
| Acknowledgment that UC received Orientation in his or her language (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.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been completed | ||||||||||||
| • 48 hours | 0 | 0 | 0 | 0 | 0 | |||||||
| • Refresher every 90 days | 0 | 0 | 0 | 0 | 0 | |||||||
| Documentation that UC Received Program Pamphlet (Pamphlet should include care provider's P&P related to SA/SH, UC's Right and Responsibilities related to SA/SH, how to contact diplomatic and consular personnel) | 0 | 0 | 0 | 0 | 0 | |||||||
| Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment | 0 | 0 | 0 | 0 | 0 | |||||||
| 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 UC received should include names, descriptions, addresses and phone numbers of national/local organizations.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Other Orientation Forms (insert below) | 0 | 0 | 0 | 0 | 0 | |||||||
| 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.) |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Birth Certificate | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 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.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| EOIR docs (Executive Office for Immigration) | 0 | 0 | 0 | 0 | 0 | |||||||
| Court Documents/Criminal History Records (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer) | 0 | 0 | 0 | 0 | 0 | |||||||
| Authorization for Release of Records (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| Medical Documents | ||||||||||||
| Authorization for Medical, Dental, and Mental Health Care (signed by care provider within 24 hours) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 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) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Immunization Records | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 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) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Prescriptions (including Prescription log.) | 0 | 0 | 0 | 0 | 0 | |||||||
| 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) | 0 | 0 | 0 | 0 | 0 | |||||||
| Communicable Diseases | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 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.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Diagnosis List | 0 | 0 | 0 | 0 | 0 | |||||||
| Copies of Referrals for Medical Services | 0 | 0 | 0 | 0 | 0 | |||||||
| Medical or Mental Health Records (including over-the-counter medications, diagnosis, and documentation of communicable diseases if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| UC 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.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Official COVID-19 vaccination record (Provided at time of vaccination. Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
0 | 0 | 0 | 0 | 0 | |||||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Scanned copy uploaded to File section of UC Portal Health Tab) Previous Version: 6/10/21 |
0 | 0 | 0 | 0 | 0 | |||||||
| Assessments | ||||||||||||
| Risk Assessment | ||||||||||||
| • Within 72 hours | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Updated every 30 days | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| UC 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.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| UC 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.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • 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 UC or other sources (e.g. KYRs) OR |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Every 30 calendar days after admission opens NEW UC Case Review OR | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Anytime there is a substantial change in the UC's case information | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Sponsor Assessment (Current version: 7/14/21; 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 UC Case Review.) Previous version(s): 6/26/19 |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Required or relevant information that was unknown during the time of the assessment is later received by the care provider. OR |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Additional information is obtained from the sponsor, UC, UC’s family, home study provider, adult caregiver, adult household members, law enforcement or a government entity. |
0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Individual Service Plan (Effective: 12/6/16 - Within 5 days.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Individual Service Plan Update | ||||||||||||
| • Every 30 days in care OR | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| • Any time there is a substantive change in UC's case information | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 days of admission into ORR care. If UC is a transfer, KYRS only required at first care provider.) The program is responsible for documenting KYRs in the UC Assessment, UC 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. | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Educational Services | ||||||||||||
| Summary of Educational Assessment (Assessment must be administered within 72 hours, excluding weekends and holidays.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes.) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Class Attendance (Effective 1/2/19) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Case Management | ||||||||||||
| Case Manager Progress Notes (1 per week) | 0 | 0 | 0 | 0 | 0 | |||||||
| Quality of Case Manager Notes | 0 | 0 | 0 | 0 | 0 | |||||||
| 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.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Phone Log (two 10 minute phone calls per week and list of approved contacts in the UC case file) | 0 | 0 | 0 | 0 | 0 | |||||||
| Religious Services Log | 0 | 0 | 0 | 0 | 0 | |||||||
| Visitor Log | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Stipend Log (Only if stipends are mandated by state licensing) | 0 | 0 | 0 | 0 | 0 | |||||||
| Clinical Services | ||||||||||||
| Clinical Progress Notes - Individual Counseling (1 per week) | 0 | 0 | 0 | 0 | 0 | |||||||
| Quality of Clinical Notes | 0 | 0 | 0 | 0 | 0 | |||||||
| Progress Notes Related to Mental Health Services (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| 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) | 0 | 0 | 0 | 0 | 0 | |||||||
| Incident Reports | ||||||||||||
| SIRS (time sensitive) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Internal Incidents | 0 | 0 | 0 | 0 | 0 | |||||||
| Grievances | 0 | 0 | 0 | 0 | 0 | |||||||
| Discharge | ||||||||||||
| Family Reunification Packet (Sponsor must sign the Family Reunification Application agreeing to the terms of the Sponsor Care Agreement. Current Version: 5/19/21) Previous Version(s): 1/31/20; 06/27/19 | 0 | 0 | 0 | 0 | 0 | |||||||
| Log of Property returned/disbursedat Discharge | 0 | 0 | 0 | 0 | 0 | |||||||
| 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.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Release Request (verify that the FFS has approved the release) | 0 | 0 | 0 | 0 | 0 | |||||||
| Discharge Notification | 0 | 0 | 0 | 0 | 0 | |||||||
| Verification of Release (Effective: 6/5/15 - Not complete unless document has a date) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Log/checklist including all documents provided to UC at discharge Checklist should include: | 0 | 0 | 0 | 0 | 0 | |||||||
| Sponsor Care Agreement | 0 | 0 | 0 | 0 | 0 | |||||||
| DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.) | 0 | 0 | 0 | 0 | 0 | |||||||
| Educational assessments and records | 0 | 0 | 0 | 0 | 0 | |||||||
| Change of Venue/Change of Address forms | 0 | 0 | 0 | 0 | 0 | |||||||
| Post-release safety plan (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16) | 0 | 0 | 0 | 0 | 0 | |||||||
| ORR National Call Center Flyers and Wallet Cards | 0 | 0 | 0 | 0 | 0 | |||||||
| CDC Covid-19 Fact Sheet and Symptoms Sheet (Effective: 3/13/20) | 0 | 0 | 0 | 0 | 0 | |||||||
| Covid-19 Discharge Sponsor Letter (English and Spanish versions. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
0 | 0 | 0 | 0 | 0 | |||||||
| Official COVID-19 vaccination record (Provided at time of vaccination and should be in the child’s discharge packet at the time of unification. Current Version: 1/28/22; Effective 6/10/21.) Previous Version: 6/10/21 |
0 | 0 | 0 | 0 | 0 | |||||||
| COVID-19 Vaccine Sponsor Letter (Current Version: 1/28/22; Effective 6/10/21. Should be in the child’s discharge packet at the time of unification.) Previous Version: 6/10/21 |
0 | 0 | 0 | 0 | 0 | |||||||
| Discharge Checklist - Medical Records | 0 | 0 | 0 | 0 | 0 | |||||||
| Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed with LTBI or TB exposure) | 0 | 0 | 0 | 0 | 0 | |||||||
| Copy of Order of Removal (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| Copy of Trafficking Eligibility Letter (if applicable) | 0 | 0 | 0 | 0 | 0 | |||||||
| Transfer to another ORR Care Provider (Non-Influx Site) | ||||||||||||
| All Family Reunification Forms and Supporting Documentation | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Care Provider Family Reunification Checklist | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Medical Checklist for Transfers | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Transfer Request and Tracking Form | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS regarding regional practices/use of this form) | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | ||
| 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 UC’s release) | 0 | 0 | 0 | 0 | 0 | |||||||
| Health Follow-Up Call (Effective 4/6/20: Must follow up with sponsor for 14 days after release date; document if UC is experiencing acute respiratory symptoms) | 0 | 0 | 0 | 0 | 0 | |||||||
| Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document | ||||||||||||
| Comments: | ||||||||||||
| Trends/Patterns: |
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| Covid-19 Update | ||||||||||||
| Effective 3/20/20 delays in meeting deadlines due to Covid-19 related contraints must be documented |
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| UC Case # (1-10) | Service | Date | Duration | Notes |
| File Type | application/vnd.openxmlformats-officedocument.spreadsheetml.sheet |
| File Modified | 0000-00-00 |
| File Created | 0000-00-00 |