UC Case File Checklist (Form M-8A) 2.26.23

Status: Original and derived artifacts are available for this document.

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OMB 0970-0564 [valid thr

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR
document care provider compliance with ORR policies and procedures related to case file maintenance during quarterly site visits. Public reporting bu
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
instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Ho
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
Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please cont
[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, base
that you review (i.e., the tabs titled "UC_CL_#"). A few important things to know across the "UC_CL_Summary" an
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 an
are:
• Present, compliant: The document is in the case file/UC Portal, and there are no issues with it. The docume
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. Fo
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 o
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,
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 ju
remain
consistent
across
file you review.
• In these
tabs, some
cellseach
are unlocked,
which enables you to input information / data. Other cells, in contrast, are
editable. For both unlocked and locked cells, you can modify the width/height/area of a cell by pulling the row/colum
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 a
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
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 d
• Input information / data for the two individual clinical services into the next two rows and select Individual C
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 Mana
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
column of this tab. For example, since UC #1 above received 10 services, you'd input "1" into the first column of th
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.
(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 com
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 th
accordingly.* Try to limit sensitive PII found in the checklist on MS Teams. When you move the checklists to t
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
would. You might have corresponding file(s) with the sensitive PII noted for reference as you work on the che
password-protect any corresponding files. When you are ready to save the final version of the checklists to th
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 w
information that is linked or linkable to a specific individual.” Examples of PII include name, phone number, email ad
Security number, as well as information that is personally identifiable when linked with other information such as, in s
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, e
• Citizenship or immigration status in combination with other identifiable information (such as name, passport numb
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, p

• Sexual orientation in combination with other identifiable information (such as name, passport number, phone num
• Criminal history in combination with other identifiable information (such as name, passport number, phone numbe
• Current or previous personal contact information (such as home address, personal phone number, personal e-ma
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: 2/22/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Ensure all medical and mental health section are fully completed.
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)
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
Not reviewed
Not reviewed
Bryson,
Wanda (ACF):

Not reviewed

Other Admission Forms (insert below)

Not reviewed
Bryson, Wanda
(ACF):

Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed

Removed the "4" from the "2-4
hours of admission" to focus on the
Not reviewed
requirement for shelter programs
only.

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)

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

Added the statement

"Should include…"
Not reviewed

Bryson,
Wanda (ACF):
Not reviewed

New line item added in
regards to "Garza v. Azar"
orientation

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)
Documentation of Initial Medical Exam (Within 48 business 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.
Immunization Records
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 entry into the UC Portal
Health tab.

Bryson,
Wanda
Not reviewed
(ACF):

Added "of admission"
to (Signed and initialed
Not
within
24reviewed
hours of
Not reviewed
admission

Not reviewed

Not reviewed
Not reviewed

Bryson,
Wanda (ACF):
Not reviewed
Added
Not"Review"
reviewedto (Executive
Office
forreviewed
Immigration
Not
Review)
Not reviewed

Not reviewed
Bryson,
Wanda (ACF):

Added "of admission" to
(signed
care provider
Notby
reviewed
within 24 hours of
admission)

Not reviewed
Not reviewed

Bryson, Wanda (ACF):

Added...
"Within 48 hours of admission"
and

reviewed completion ofNot
"*AsNot
a reminder,
thereviewed
Initial Medical Exam form
is mandatory
by the healthcareNot
provider
(HCP) unless the HCP
Not reviewed
reviewed
provider is employed by the grantee and enters the data
directly into the UC Portal/Path during the evaluation."
Bryson, Wanda (ACF):

Added "Dental Exam Form must be completed

Prescriptions (including Medication Administration Record/log)

Not reviewedby the dentist by the conclusion of all dental

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(ACF):

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

visits and returned to the care provider
program for review and etnry into the UC Portal
Health tab.

Bryson, Wanda
Added "Record"

Page 3 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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)

Not reviewed
Bryson,
Wanda
(ACF):

Not reviewed

• Subsequently every 30 calendar days after admission opens NEW UC Case Review OR

Not reviewed
Bryson, Wanda
(ACF):
Not"Subsequently"
reviewed
Added

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
Bryson, Wanda
(ACF):

Not reviewed

• Required or relevant information that was unknown during the time of the
assessment is later received by the care provider. OR
• Additional information is obtained from the sponsor, UC , UC ’s family, home
study provider, adult caregiver, adult household members, law enforcement or a
government entity.

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Bryson, Wanda
(ACF):

Not reviewed

• Anytime there is a substantial change in the UC 's case information

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care AND
• Any time there is a substantive change in UC 's case information
Know Your Rights (KYRs) Presentation (Should be conducted within 7-10 business 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.

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Added "Initial case
review "

Not reviewed

Added ""Must be
initiated"

Added " Initial must be
reviewed
doneNot
within"

Not reviewed

Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
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.)
Phone Log (two 10 minute phone calls per week and list of approved contacts in the
UC case file)
Religious Services Log
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)
Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)
Incident Reports
SIRS (time sensitive)

Not reviewed
Not reviewed
Not reviewed
Bryson, Wanda (ACF):
Added "Plan"

Removed "(Effective 3/20/20 - avoid
community
outings due to Covid-19.)"
Not reviewed

Not reviewed
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Not reviewed
Page 4 of 36

Internal Incidents
Grievances

Not reviewed
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
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
ORR National Call Center Flyers and Wallet Cards
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 5 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 6 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 7 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 8 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 9 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 10 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 11 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 12 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 13 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 14 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 15 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 16 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 17 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 18 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 19 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 20 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 21 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 22 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 23 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 24 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 25 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 26 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 27 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 28 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 29 of 36

ORR/UCP Master Case File Checklist - OPEN/CLOSED
(Updated: 2/17/23)

Reviewer:
UC Name:
Nationality:
Admitted Date:
Date of Release:

Release Category:
Date:
A#:
Case Manager:
DOB:
Clinician:
Gender:
Transfer?
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)
Placement Authorization Form (signed by care provider within 24 hours.)
UC Photo (within 24 hours) (Recommendation only: Babies every 6 months; All other
UC annually)

Not reviewed
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.)
Documentation that an Orientation related to the “Garza v. Azar” court ruling has been
completed, if applicable (48 hours, translated into UC language)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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
Not reviewed
Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

Not reviewed
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.)
Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)
EOIR docs (Executive Office for Immigration Review)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)
Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours of admission)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

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 ORRfunded 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
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

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
Copies of Referrals for Medical Services
Medical Records (including over-the-counter medications, diagnosis, and
documentation of communicable diseases if applicable)

Not reviewed
Not reviewed
Not reviewed

Page 30 of 36

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

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

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
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
Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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

Not reviewed
Not reviewed
Not reviewed

Not reviewed
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
• 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

Not reviewed

Not reviewed

Individual Service Plan (Effective: 12/6/16 - Initial must be done within 5 days of
admission)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC 's case information

Not reviewed

Not reviewed

Not reviewed
Not reviewed

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

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Not reviewed

Educational Services
Summary of Educational Assessment (Assessment must be administered within 72
hours, excluding weekends and holidays.)
Educational Plan ("Plan" should include information on UC class placement,
curriculum/course descriptions, and Records (academic reports, progress notes.)
Class Attendance (Effective 1/2/19)

Case Management
Case Manager Progress Notes (1 per week)
Quality of Case Manager Notes
Logs:
Recreation/Leisure Activity 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
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
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

Not reviewed
Not reviewed
Not reviewed

Clinical Services
Disclosure Notice (completed by a clinician within 5 days of admission and prior to the
UC Assessment)
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)

Not reviewed

Not reviewed

Not reviewed

Not reviewed
Not reviewed
Not reviewed
Not reviewed

Incident Reports
Page 31 of 36

Not reviewed
Not reviewed
Not reviewed

SIRS (time sensitive)
Internal Incidents
Grievances
Discharge
Family Reunification Packet (Sponsor must sign the Family Reunification Application
agreeing to the terms of the Sponsor Care Agreement. Current Version 13, Effective:
12/28/22) Previous Version(s): 5/19/21, 1/31/20; 06/27/19
Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)

Not reviewed

Not reviewed

Not reviewed
Not reviewed

Release Request (verify that the FFS has approved the release)
Discharge Notification

Not reviewed
Not reviewed

Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)

Not reviewed

Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter, I-360 approval notice, asylum letter etc.)
Educational assessments and records
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Discharge Checklist - Medical Records
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)

Not reviewed
Not reviewed

Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

Not reviewed
Not reviewed

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)

Not reviewed
Not reviewed
Not reviewed
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

Not reviewed
Not reviewed
Not reviewed
Not reviewed
Not reviewed

Not reviewed

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update

Page 32 of 36

Case File # Reviewed

# Case File: Present,
compliant

# Case File: N/A

Portal #
Reviewed

# Portal: Not
present

# Portal: N/A

0

0

0

0

0

0

0

0

0

0

Placement Authorization Form (signed by care provider within 24 hours.)
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

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
Other Admission Forms (insert below)

0
0

0
0

0
0

0
0

0
0

0

0

0

0

0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Acknowledgement of receiving information regarding local and/or national service
providers and organizations that provide services to victims of sexual abuse and sexual
harassment. (Signed. Information UC received should include names, descriptions,
addresses and phone numbers of national/local organizations.)

0
0

0
0

0
0

0
0

0
0

Other Orientation Forms (insert below)

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Birth Certificate
Supporting Docs from Referring Federal Agency (uploaded within 24 hours if referred by
DHS, as available; e.g. DHS docs: medical/mental health/safety concern docs,
criminal/juvenile records.)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

EOIR docs (Executive Office for Immigration)
Court Documents/Criminal History Records (if applicable)
G-28 (Notice of Entry of Appearance) (if UC is represented by a lawyer)
Authorization for Release of Records (if applicable)

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Immunization Records
Record of Dental Exam(s) (Initial > 60, but < 90 days after admission. Effective 05/02/17
Portal: Initial Dental Exam, regardless of final outcome, should be recorded in the Health
Tab; Recommendation every 6 months thereafter)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Prescriptions (including Prescription log.)
TB Screening Results (if diagnosed with latent TB (LTBI), check if there is a letter in the
case file at discharge. Current Version - expiration: 05/31/22. Previous Version expiration: 11/30/18)
Communicable Diseases
Records of Office Visits/ER Visits/Hospital, Surgery (Medical information should be
uploaded in respective section of Health tab; Mental health visits should be entered as
Medical Complaint reports in the Health tab if the child is seen by a psychiatrist and/or
prescribed a medication.)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

Diagnosis List

0

0

0

0

0

Copies of Referrals for Medical Services
Medical or Mental Health Records (including over-the-counter medications, diagnosis,
and documentation of communicable diseases if applicable)

0
0

0
0

0
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

Admission Documents
Initial Intakes Assessment (within 24 hours)

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.)
Documentation that an Orientation on Sexual Abuse and Sexual Harassment has been
completed
• 48 hours
• Refresher every 90 days
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)

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.)

Medical Documents
Authorization for Medical, Dental, and Mental Health Care (signed by care provider
within 24 hours)
Documentation of Initial Medical Exam (unless the minor obtained a medical exam
within one calendar year while under the care of another ORR-funded care provider.
Current Version - expiration: 05/31/22. Previous Version - expiration: 11/30/18)

Assessments
Risk Assessment
• Within 72 hours
• Updated every 30 days
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.)

# Case File: Present,
# Case File: Not present
noncompliant

# Portal: Present, # Portal: Present,
compliant
noncompliant

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
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
• Anytime there is a substantial change in the UC's case information
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
0
0

0
0
0

0
0
0

0
0
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
• 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

0

0

0

0

0

0

0

0

0

0

Individual Service Plan (Effective: 12/6/16 - Within 5 days.)
Individual Service Plan Update
• Every 30 days in care OR
• Any time there is a substantive change in UC's case information
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

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0

0

0

0

0

0

0

0

0

0

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)
Quality of Case Manager Notes
Logs:

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.)
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

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)
Religious Services Log
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)

0

0

0

0

0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

0
0
0

Clinical Services
Clinical Progress Notes - Individual Counseling (1 per week)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (2 per week OR 1 group counseling and 1 community
meeting; should include acculturation and adaptation services such as developing social
and interpersonal skills)
Incident Reports
SIRS (time sensitive)
Internal Incidents
Grievances

Notes

Page 33 of 36

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

0
0

0
0

0
0

0
0

0
0

0

0

0

0

0

0

0

0

0

0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
0
0
0
0
0

0
0
0
0
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
Letter to Sponsor for UC with latent TB or TB Exposure (ONLY for UC who are diagnosed
with LTBI or TB exposure)
Copy of Order of Removal (if applicable)
Copy of Trafficking Eligibility Letter (if applicable)

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0

0

0

0

0

0

0

0

0

0

Log of Property returned/disbursedat Discharge
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and
initialed. Current Version: 04/04/19. Previous Versions: 09/20/16, 02/09/15, 05/10/13,
02/14/13, 10/22/12. List for CA - Current Version: 07/26/16.)
Release Request (verify that the FFS has approved the release)
Discharge Notification
Verification of Release (Effective: 6/5/15 - Not complete unless document has a date)
Log/checklist including all documents provided to UC at discharge Checklist should
include:
Sponsor Care Agreement
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility
letter,
I-360 approval
notice,
Educational
assessments
andasylum
recordsletter etc.)
Change of Venue/Change of Address forms
Post-release safety plan (if applicable)
Zika Letter and Fact Sheet (if applicable) (Effective: 06/14/16)
ORR National Call Center Flyers and Wallet Cards
CDC Covid-19 Fact Sheet and Symptoms Sheet (Effective: 3/13/20)
Covid-19 Discharge Sponsor Letter (English and Spanish versions. Current Version:
1/28/22; Effective 6/10/21.)
Previous Version: 6/10/21

Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
Care Provider Family Reunification Checklist
Medical Checklist for Transfers
Transfer Request and Tracking Form
Notice of Transfer to ICE Chief Counsel COA/COV (If applicable. Note: Refer to FFS
regarding regional practices/use of this form)
Post-Discharge
Safety & Well Being Follow-up Call (Effective: 3/14/16; all call attempts must be made
within 7 days following the 30-day mark of the UC’s release)
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
0

0
0
0

0
0
0

0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

0
0
0
0
0

Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:

Trends/Patterns:

Covid-19 Update
Effective 3/20/20 delays in meeting deadlines due to Covid-19 related contraints must be documented

Page 34 of 36

UC Case # (1-10)

Service

Date

Duration

Notes