S-6 Home Study Assessment - UC Path Version

Home Study Assessment (Form S-6)
Home Study Tab

that will require additional support or strengths-based services after release from ORR custody?

Dropdown Options:
Unemployed
Part-time
Full-time
Other

Dropdown Options:
Single Family Home
Townhome
Apartment
Mobile Home
Other

Dropdown Options:
Approved
Not Approved
Unknown

Dropdown Options:
Yes
No
Dropdown Options:
Yes
No
Dropdown Options:
Yes
No
Dropdown Options:
Yes
No
Dropdown Options:
Yes
No

Dropdown Options:
Yes
N/A – No others noted to be living in
home
Dropdown Options:
Yes
No

Dropdown Options:
Yes
No
Dropdown Options:
Yes
No

Dropdown Options:
Highly Equipped
Moderately Equipped
Not Sufficiently Equipped

OMB 0970-0553 [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to identify and assess the UAC’s risk for suicide. Public reporting burden for this collection of information is estimated to
average 0.75 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].
UAC-S-6 [Rev. MM/DD/YYYY]

Household Members Data Entry Window
Dropdown Options:
See table below

Dropdown Options:
Male
Female
Transgender
Other
Dropdown Options:
Yes
No

Dropdown Options:
Yes
No

Dropdown Options for Relationship to Sponsor and Relationship to UC:

Aunt
Brother
Brother-in-law
Daughter
Family Friend
Father
First Cousin
Goddaughter
Godfather
Godmother
Godson
Granddaughter
Grandfather
Grandmother
Grandson
Mother
Nephew
Niece
Other Cousin
Other Distant Relative

Sister
Sister-in-law
Son
Sponsor’s Partner
Step Brother
Step Daughter
Step Father
Step Mother
Step Sister
Step Son
UC’s Spouse
Uncle
Half-Sibling
Institutional/Organizational Sponsor
Legal Guardian
Parent’s Partner
Qualified Step-Parents
Unknown
Unrelated Sponsor

Community Resources Data Entry Window

Dropdown Options:
School
Mental Health
Community Resource

Summary and Certification Tab
Dropdown Options:
Positive Home Study Recommendation
Negative Home Study Recommendation
Dropdown Options:
Pending Supervisor Review
Approved by Supervisor
Submitted