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pdfInitial Intakes Assessment
OMB 0970-0553 [Valid through 02/28/2021]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to screen
UAC for trafficking or other safety concerns, special needs, danger to self and others, medical conditions, and mental health concerns. Public reporting burden for this collection
of information is estimated to average 0.25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number.
If you have any comments on this collection of information please contact [email protected].
Vomiting
Yes
No
Abdominal Pain
Yes
No
Coughing Blood
Yes
No
Nausea
Yes
No
Skin lesions/rash
Yes
No
Severe/persistent headache
Yes
No
Jaundice (Yellowing of the skin/whites of eyes)
Yes
No
Neurological symptoms (Spasm, tics, uncontrollable movements,
paralysis or numbness of any part of the body)
Yes
No
Others(list)
Yes
No
If Yes, specify:
If injuries, wounds, bruises present, describe them and how they occurred:
List of other medical concerns:
Have you ever been to a doctor or stayed in a hospital?
Yes
No
Yes
No
Yes
No
Yes
No
If yes, please list any visit or stay for any reason. Also include visits to other healers or alternative treatment providers:
Do you have a history of tuberculosis?
If yes explain:
Do you have a history of seizures of convulsions?
If yes explain:
Do you have any scars, birthmarks, or tattoos?
If yes explain:
Mental Health (Check all that apply)
If the child answered “Yes” to any of the below mental health questions and/or if any concerning behaviors or emotions were observed or reported, immediately report
your concerns to the Clinician, Lead Case Manager, Program Director, or Shift Supervisor for further guidance on the need to seek mental health care.
Concern
Yes/NO
Tried to hurt yourself?
Yes
No
Had urges to beat, injure or harm someone?
Yes
No
Harmed anyone?
Yes
No
Thought of attempting suicide or hurting yourself?
Yes
No
Attempted suicide?
Yes
No
Heard voices that others do not?
Yes
No
Seen things or people that others do not see?
Yes
No
Had trouble controlling anger or violent behavior?
Yes
No
Are you having thoughts of harming yourself or someone else?
Yes
No
Please explain any checked answers above:
Observable emotional concerns (Check all that apply)
Concern
Yes/NO
Cooperative
Yes
No
Uncooperative
Yes
No
Alert
Yes
No
Distracted
Yes
No
Calm
Yes
No
Excited
Yes
No
Nervous
Yes
No
Agitated
Yes
No
Confused
Yes
No
Sad
Yes
No
Angry
Yes
No
Other
Yes
No
If Yes, specify:
Are you having thoughts of harming yourself or someone else?
Safety Assessment
If the child answered “Yes” to any of the below safety assessment questions, immediately report concerns to the Clinician, Lead Case Manager, Program Director, or
Shift Supervisor for further guidance on how to ensure the child’s safety.
Do you feel safe now?
Yes
No
Yes
No
Explain if No:
Do you fear that someone will harm you?
Explain if yes:
Explain to the child where the child’s room will be located in the facility, the number of potential roommates, the age and sex of the roommates, and the bathroom and shower area
associated with the potential room assignment. After having explained this, does he or she identify any specific fears about this potential housing assignment?
Do you need anything right now?
INTERVIEWER SUMMARY OF CRITICAL ISSUES THAT NEED IMMEDIATE
ATTENTION:
List any issues rated above as urgent or significant and your actions to address them.
Deliver this form to the Lead Case Manager, Clinician, or other SUPERVISOR
designated to follow-up care.
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1
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ACTIONS TAKEN:
Each action should correspond to the issues noted at left.
Staff Signature:
Date:
Staff Name:
Staff Title:
Translator's Signature:
Date:
Translator's Name:
Language:
Yes No
| File Type | application/pdf |
| File Modified | 2020-12-22 |
| File Created | 2020-04-02 |