Form M-8B-UF Unlicensed Facility Foster Care Unaccompanied Child Case

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Overview

Checklist
Services

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Sheet 1: Checklist

					OMB 0970-0564 [valid through MM/DD/2026]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR contractor monitors to document care provider compliance with ORR policies and procedures related to case file maintenance during quarterly site visits. Public reporting burden for this collection of information is estimated to average 1.0 hour per response for the care provider and 6.0 hours for the contractor monitor, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments on this collection of information please contact [email protected].
Unlicensed Facility ORR/UCP LTFC Master Case File Checklist - OPEN/CLOSED (Updated: 02/23/2021)
Reviewer:		Date:			Release Category:
UC Name:		A#:
Nationality:		DOB:			Case Manager:
Admitted Date:		Gender:			Clinician:
Date of Release:		Language(s):			Transfer from:
Foster Parent/Group Home Name:		Religion:
Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
		CF	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)
Inventory of all Property and Cash (Signed within 24 hours. 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)
Clothing and Supplies distributed to UC
Other Admission Forms (insert below)
Orientation Documents (48 hours, translated into UC language)
Acknowledgement of Orientation (Signed. Note in English indicating purpose of document. Should include: Foster Family Rules. 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 (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)
Documentation that UC Received ORR Pamphlet on Sexual Abuse and Harassment
Other Orientation Forms (Insert below)
Legal Information
Acknowledgement of receiving the Legal Resource Guide at admission (Signed and initialed within 24 hours. Current Version: 4/4/19. Previous Versions: 9/20/16, 2/9/15, 5/10/13, 2/14/13, 10/22/12. List for CA - Current Version: 07/28/16.)
Birth Certificate
Supporting Docs from Referring Agencies (Uploaded within 24 hours) (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. Note: Most UC in LTFC will have 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)
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, and there is documentation of receiving the medical exam; Current Version - expiration: 05/31/22. Previous Version - expiration: 11/30/18)
Immunization Records
Record of Dental Exam(s) (Initial within 60-90 days of admission into ORR care; Effective 5/2/17 Portal: Initial Dental Exam, regardless of final outcome, should be recorded in the Health Tab; Recommendation every 6 months thereafter)
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 reports should be uploaded under "Historical Medical Record" under CM tab and related documentation should be uploaded under "UC Documents.")
Diagnosis List
Copies of Referrals for Medical Services
Progress Notes Related to Medical Health Services (if applicable)
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.)
Assessments
Risk Assessment
• Within 72 hours
• Updated every 90 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.)
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.
• Continuously updated until 90 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
• Subsequently every 90 calendar days OR
• Substantial changes or Additional Information is received
Sponsor Assessment (If applicable; (Current version: 6/24/19; 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: 12/6/16
• 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.
In Care Plans
Individual Service Plan (Effective: 12/6/16 - Within 5 days.
Individual Service Plan Update
• Every 90 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.
Independent Living Skills Plan
Recreation and Leisure Time Plan/Log (Given that UC are with foster families for longer periods of time, recreational activity log can be a "plan" instead of a log) (Effective 3/20/20 - avoid community outings due to Covid-19.)
Acculturation and Adaptation Services Plan
Religious Services Plan/Log
Individualized Safety Plan (if appropriate)
Educational Services
Summary of Educational Assessment (within local school timeframe)
Educational Plan ("Plan" should include information on UC class placement, curriculum/course descriptions, and Records (academic reports, progress notes)).
Individualized Education Plan (IEP), if applicable
Class Attendance (Effective 1/2/19)
Opportunities for Vocational Education
Case Management
Case Manager Progress Notes (1 meeting per month, preferably in person)
Quality of Case Manager Notes
UC Long Term Foster Care Travel Requests (Submitted at least 10 days prior to trip departure for any travel or overnight trip request requiring custodian consent by state regulations or any involving a child with flight risk or safety concern)
Record of Placement Changes (Effective 1/2/19)
Logs:
Phone Log (Only required if there is a safety concern)
Visitor Log
Stipend Log (Only if stipends are mandated by state licensing)
Clinical Services
Clinical Progress Notes - Individual Counseling (Per signed LTFC addendum to Cooperative Agreement, the provider will alternatively complete individual counseling as needed by qualified mental health professional.) Recommendation: Clinician should still check in periodically with UAC to see if UAC changes mind about counseling services.)
Quality of Clinical Notes
Progress Notes Related to Mental Health Services (if applicable)
Group Counseling Notes or Record (Recommendation. Per signed LTFC addendum to Cooperative Agreement, the provider is not required to conduct two group counseling sessions per week.)
Incident Reports
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: 1/31/20) Previous Version: 06/27/19
Post-18 Planning (completed at least two weeks before youth's 18th birthday) (recommendation: copy maintained in case file)
Acknowledgement of receiving the Legal Resource Guide at Discharge (Signed and initialed. Current Version: 4/4/19. Prior Versions: 9/20/16, 2/9/15, 5/10/13, 2/14/13, 10/22/12. List for CA - Current Version: 07/26/16)
Log of Property returned and distributed while in care at Discharge
Release Request (FFS must approve the release)
Discharge Notification
Verification of Release Form (Effective: 6/5/15 - not complete unless document has a date)
Log/checklist including all documents provided to UC at discharge Checklist should include:
DHS and Immigration case related documents (i.e. Form I-862, trafficking eligibility letter, I-360 approval notice, asylum letter etc.)
Verification of Release
Birth Certificate
Original, notarized Letter of Designation for Care of a Minor (if applicable)
Educational assessments and records
Sponsor Care Agreement (if applicable)
Name and contact information of medical, mental health, and dental care providers while in care
Change of venue/change of address forms
Post-release safety plan as needed
Zika Letter and Fact Sheet (Effective: 06/14/16)
ORR National Call Center Flyers and Wallet Cards
CDC Covid-19 Fact Sheet and Symptoms Sheet (Effective: 3/13/20)
Discharge Checklist - Medical Records
COVID-19 Symptom and Temperature Check at the Time of Discharge or Transfer Form (Effective: 7/16/2020)
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)
Transfer to another ORR Care Provider (Non-Influx Site)
All Family Reunification Forms and Supporting Documentation
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)
COVID-19 Symptom and Temperature Check at the Time of Discharge or Transfer Form (Effective: 7/16/2020)
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)
Orange Fill = Flores Minimum Requirement; Gray Fill = Important Document
Comments:
Trends/Patterns:

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Sheet 2: Services

Individual Clinical Services (pg)

Clinical Group Services (pg)

Community Group Meetings - "YCW Led Groups" (pg)

Case Management (pg)

Recreation - LMA (pg)

Activities - Leisure (pg)

Religious Services (pg)

Phone Log (pg)

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*Check that recreation activities are varied.