Form P-10A Transfer Request

6/29/23, 1:48 PM

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Welcome:  Liane

UC Basic Information
First Name:

Kaminska

AKA:

Last Name:

Fake

Status:

ADMITTED

Date of Birth:

3/31/2005 (Age 18)

Admitted Date:

6/28/2023

A#:

732895423

Length of Stay:

1 Days

Country of Birth:

Egypt

Current Program:

A New Leaf – Dorothy Mitchell

Gender:

F

Portal ID:

696178

Transfer Request
Request Details
Requested Program Type*

Requester Name*

Requester Title

Requester Phone

Reason for Transfer Request
Transfer Type*
To Any Program

To Provide Less Restrictive Se ng
To Provide More Restrictive Se ng
Minor`s Medical Health
Minor`s Mental Health
Violent/Threatening Behavior
Disruptive Behavior
Minor`s Safety
Runaway Risk

To Restrictive Placements

Convicted as Adult
Adjudicated Delinquent
Criminal Charges
Chargeable

Between Programs

Program Capacity
Proximity to UC Relative
Proximity to Potential Sponsor
ICF Ineligible
Physical Placement in Program

Please select at least one reason for transfer.

Legal Information
Minor Has Attorney of Record?*

Yes

No

Attorney of Record
Attorney Phone
Casefile Summaries
Information Relating to Minor's

Pregnancy

Casefile

Injury
Illness
Non-Diagnosed Behavior / Illness with no Medications
Non-Diagnosed Behavior / Illness with Medications
Diagnosed Behavior / Illness with no Medications

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Diagnosed Behavior / Illness with Medications
Non-Violent Conviction
Non-Violent Charge
Charge(s) Dropped

Please select a description of the Illness
Minor's Medical Health Summary*

32000 characters left.
Minor's Mental Health Summary*

32000 characters left.
Behavior Summary*
(Runaway Risk, Aggressive/
Assaultive and Sexually
Inappropriate Behaviors)

32000 characters left.

Current Status of Family
Reunification*

32000 characters left.
Immigration Court Status*

32000 characters left.

Case Manager Recommenda on
Case Manager Name*
Date of Case Manager Comments*

mm/dd/yyyy

Case Manager Comments*

32000 characters left.

Case Manager Suggests Transfer?*

Yes

No

Case Coordinator Third Party Review
Case Coordinator Name*
Date of Case Coordinator Review*

mm/dd/yyyy

Case Coordinator Comments*

32000 characters left.

Concur with Requesting Party?*

Yes

No

ORR Transfer Request Decision
ORR Decision Maker Name*
Date of ORR Decision*

mm/dd/yyyy

ORR Decision Maker Comments*

32000 characters left.

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ORR Decision*

UC™ Portal
Approve
Disapprove
On Hold (Provide Detail in Comments)
Submit Request

Save Draft

Cancel Referral

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to process recommendations
and decisions for transfer of a child within the ORR care provider network. Public reporting burden for this collection of information is estimated to average 0.25 hours per grantee case
manager and 0.17 hours per contractor case coordinator (a total of 0.42 hours), including the time for reviewing instructions, gathering and maintaining the data needed, and
reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not
required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The
OMB control number is 0970-0554 and the expiration date is 06/30/2026. If you have any comments on this collection of information please contact [email protected].

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