R-6 Safety and Well-Being Call Report - Modernized UC Portal

OMB 0970-0552 [valid through MM/DD/YYYY]

Administration for Children & Families

Office of Refugee Resettlement

Virtual Check-In Questionnaire

Pre-Call Information

CHILD INFORMATION

Child’s Name: [auto-populated]	A#: [auto-populated]
Date of Birth: [auto-populated]	Age: [auto-populated]
Name of Program Child was Released from: [auto-populated]	Length of Stay: [auto-populated]
Discharge Date: [auto-populated]	Length of Care: [auto-populated]
Days Since Discharge: [auto-populated]

SPONSOR INFORMATION

Sponsor Name: [auto-populated]
Relationship to Child: [auto-populated]	Category: [auto-populated]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]
Primary Phone: [auto-populated]	Backup Phone Number: [auto-populated]

OTHER INFORMATION

Name(s) and Phone Number(s) in Care Plan: [auto-populated]

Name(s) and Phone Number(s) in Home Country: [auto-populated]

Questions for the Sponsor

Date Sponsor Interviewed: [date picker]

LOCATION & CONTACT INFORMATION

1. Can you please confirm your current address? [text box]

Does address match? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If address is different: Did you complete a Change of Address form? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no/don’t know/refuse to answer to completing a Change of Address form: If you moved to a new address, you are required by law to file a Change of Address form with the immigration court. You can fill out the form online here (available in 6 languages): Change of Address Form (EOIR-33/IC) | EOIR Respondent Access (justice.gov)

If address is different: You can request an address update for your Verification of Release card by contacting the ORR National Call Center (NCC) at (800) 203-7001.

2. Is [child’s name] currently living with you? [dropdown – Yes/No/Refuse to Answer]

If No:

What happened? [text box]

Prompt if needed: Why did [child’s name] move?

Where is [child’s name] currently living?

¨ With Alternate Caregiver (ACG) or Non-Sponsor

ACG/Non-Sponsor Relationship to Child: [text box]

ACG/Non-Sponsor Name: [text box]

ACG/Non-Sponsor Address: [text box]

ACG/Non-Sponsor Phone: [text box]

¨ Living independently

Child Address: [text box]

¨ Known Runaway (has left placement of their own accord and whereabouts are unknown)

¨ Arrested

¨ Hospitalized

¨ Death

¨ Returned to Home Country

¨

¨ Location Unknown

When did this happen? [text box]

Did you notify ORR? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Was a Police Report made? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Was NCMEC notified? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Do you have any concerns for [child’s name]’s safety? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

3. What is the best way to contact [child’s name]?

Child Phone: [text box]

Other Phone: [text box]

Preferred Day/Time: [text box]

Notes: [text box]

4. If we’re having trouble reaching [child’s name] in the future, is there someone we can contact (including in home country, the US, or elsewhere) that would know how to reach them? [text box]

Name: [text box]

Relationship: [text box]

Phone: [text box]

Email: [text box]

Address: [text box]

Other: [text box]

Notes: [text box]

5. Comments: [text box]

CHILD’S SCHOOL

1. Is [child’s name] enrolled and going to school? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Name of School: [text box]

Grade: [dropdown – K, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, ESL, Alternative School]

Is [child’s name] facing any challenges in school? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Prompt if needed: For example, keeping up in class, completing homework, language, bullying, difficulty making friends, etc.

If yes, please explain: [text box]

If No:

Is [child’s name] registered for school? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Reason Not Registered: [dropdown (select all that apply) – Immunizations, Identity/Residency Documentation Issues, Not Planning on Registering, not of compulsory school age, not interested/willing to attend, Transportation Issues, School not in session/summer break; school resistant to enroll the child Other]

If school is resistant to enrolling the child: What reason did the school give to not enroll [child’s name]? Do you remember who told you they cannot enroll [child’s name]? Would you like assistance enrolling [child’s name] in school?

If Other, Specify: [text box]

2. Comments: [text box]

CHILD’S MEDICAL & MENTAL HEALTH

1. Do you need assistance scheduling a vaccine appointment for [child’s name]? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

2. You should have received copies of [child’s name]’s health records when they left ORR care (e.g., immunization records, lab results, office notes). Do you have copies of these records? [dropdown – Yes/No]

If no, explain how to request copies of their health records by completing the Authorization for Release of Records (ARR) and submitting to [email protected] as described in UC Policy Guide Section 5.10.1 UC Case File Request Process.

3. If [child’s name] left ORR care with medications, did they finish taking all their medication? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable] [text box]

If no, instruct the sponsor to have the child evaluated by a healthcare provider.

If applicable for chronic conditions: Do you know where to get prescription refills?

4. If [child’s name] left ORR care with a health appointment scheduled in your community, did they attend? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable]

If yes, are they still under care for that issue/condition? [dropdown – Yes/No]

If no, why not? [text box]

5. Do you know where you can take [child’s name] if they need healthcare and/or prescription refills? [dropdown – Yes/No/Refuse to Answer]

If no, provide link to a Federally Qualified Health Center.

6. Is [child’s name] having any behavioral or health issues? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Has [child’s name] seen a doctor or healthcare professional for those concerns? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Provide details about the sponsor’s concerns regarding the child, and what has been done (if anything): [text box]

7. Is there anything else you would like to share about [child’s name] or others in your home? [text box]

   1. If applicable, provide details about the sponsor’s concerns regarding the child’s medical health: [text box]

   2. If applicable, provide details about the sponsor’s concerns regarding the child’s mental health: [text box]

   3. If applicable, provide details about other concerns/information: [text box]

LEGAL SERVICES & CHILD’S IMMIGRATION COURT DATES

1. Have you attended the Legal Orientation Program for Custodians of Unaccompanied Children (LOPC)? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no, ask if the sponsor wants assistance connecting with LOPC. If the sponsor wishes to schedule themselves, offer to send another copy of the LOPC Flyer. If the sponsor request assistance, call (888-996-3848), email ([email protected]), or use the Online Scheduling System to schedule an appointment for the sponsor.

2. Are you aware of when [child’s name]’s next immigration court date will be? [dropdown – Yes/No/Refuse to Answer]

Inform the sponsor that they can call 1-800-898-7180 or visit EOIR online at https://acis.eoir.justice.gov/es/ and enter the child’s A# for an update on the child’s case. If applicable, note that they can push #2 to hear instructions in Spanish if they call.

If no, check the EOIR website while on the call and provide the sponsor the information on the child’s next immigration court hearing.

If Yes:

Did you notify [child’s name] of their court date? [dropdown – Yes/No/Refuse to Answer]

Time/Date/Place: [text box]

Is there a plan for how [child’s name] will attend their court date, for example who will take them and how they will travel there? [dropdown – Yes/No/Don’t Know/Refuse to Answer] [text box]

3. (30-Day Call) If [child’s name]’s scheduled immigration court date has passed, did [child’s name] attend? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable]

4. Do you still have [child’s name]’s Verification of Release form and/or card? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no, provide the sponsor information on how to request a new form/card.

5. Have you found an organization or attorney to represent [child’s name]’s case? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If No: Would you like assistance finding and accessing legal services? [dropdown – Yes/No]

If Yes:

Organization Name: [text box]

Attorney Name: [text box]

Phone: [text box]

Email: [text box]

6. Comments [text box]

SAFETY & WELL-BEING

1. Have you or anyone else ever been asked to pay fees or wire money for [child’s name]’s journey to the U.S. or release from ORR? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Who asked for this money? [text box]

How much did they ask for? [text box]

Did you (or someone else) send it? [dropdown – Yes/No/Refuse to Answer]

What’s the contact information of the person who asked for this money? [text box]

2. (30-Day Call) How is [child’s name]’s eating and appetite? [dropdown - very good, good, bad, very bad] If needed: [text box]

3. (30-Day Call) How has [child’s name] been sleeping at night? Dropdown - very good, good, bad, very bad ] If needed: [text box]

4. (30-Day Call) How has [child’s name] been adjusting to your home environment? [dropdown – very good, good, bad, very bad]

If needed: [text box]

5. (30-Day Call) How does [child’s name] seem to be socializing and making friends? [dropdown – very good, good, bad, very bad] If needed: [text box]

6. Is there anything else that we could help you and your family with? [text box]

7. Comments [text box]

CHILD’S WORK

1. Is [child’s name] working? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Who do they work for/what is the name of their employer? [text box]

What do they do for work? [text box]

On average, how many hours a day are they working? [dropdown – 1-24]

On average, how many days a week are they working? [dropdown – 1-7]

Are they being paid? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes: What do they do with the money? [textbox]

Prompt if needed: Are they expected to give the money to someone else for any reason, for example to pay for transportation, housing, uniforms, getting the job, etc.?

2. Comments [text box]

Questions for the Child

Date Child Interviewed: [date picker]

LOCATION

1. Can you please confirm your current address? [text box]

Does address match? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

2. Are you currently living with your sponsor? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If No:

What happened? [text box]

Prompt if needed: Why did you move?

Where are you currently living?

¨ With Alternate Caregiver (ACG) or Non-Sponsor

ACG/Non-Sponsor Relationship to Child: [text box]

ACG/Non-Sponsor Name: [text box]

ACG/Non-Sponsor Address: [text box]

ACG/Non-Sponsor Phone: [text box]

¨ Living independently

When did this happen? [text box]

3. Do you have any concerns staying in the home or with your sponsor? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

Prompt if needed: Do you feel safe and comfortable in your current living arrangement?

Prompt if needed: Is where you live what you expected it to be?

4. Do you expect or plan to move in the next month? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

Prompt if needed: Is there an alternative placement you would like to go live at in the near future?

If yes: Where, who, relationship to alternative placement.

5. Is there a preferred way for us to reach you in the future? [text box]

Phone: [text box]

Email: [text box]

Address: [text box]

Other: [text box]

Notes: [text box]

6. If we’re having trouble reaching you in the future, is there someone we can contact that would know how to reach you? [text box]

Name: [text box]

Relationship: [text box]

Phone: [text box]

Email: [text box]

Address: [text box]

Other: [text box]

Notes: [text box]

7. Comments [text box]

SCHOOL

1. Are you enrolled and going to school? [dropdown – Yes/No]

If Yes:

Name of School: [text box]

Grade: [dropdown – K, 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, ESL, Alternative School]

What do you like about your school? [text box]

What is going well? [text box]

Are you facing any challenges in school: : [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Prompt if needed: For example, keeping up in class, completing homework, language, bullying, difficulty making friends, etc.

If yes, please explain: [text box]

How many days per week do you go to school? [drop down – 1, 2, 3, 4, 5, 6, 7]

If child reports less than 5 days per week, ask them to explain their school schedule: [text box]

Would you be interested in being connected to additional education support? [dropdown – Yes/No] [text box]

If No:

Please explain: [text box]

If not enrolled already: Are you interested in attending an educational program? [dropdown – Yes/No]

If not enrolled already: Would you be interested in being connected to support enrolling in school? [dropdown – Yes/No]

2. Comments [text box]

MEDICAL & MENTAL HEALTH

1. You should have received copies of your health records when you left ORR care (e.g., immunization records, lab results, office notes). Do you have copies of these records? [dropdown – Yes/No]

If no, explain how to request copies of their health records by completing the Authorization for Release of Records (ARR) and submitting to [email protected] as described in UC Policy Guide Section 5.10.1 UC Case File Request Process.

2. If you left ORR care with medications, did you finish taking all your medication? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable]

If no, instruct the sponsor to have the child evaluated by a healthcare professional.

If applicable for chronic conditions: Do you know how where to get prescription refills?

3. If you left ORR care with a health appointment scheduled in your community, did you attend? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable]

If no, please explain: [text box]

4. How is your health? Would you say your health is very good, good, bad, very bad? [dropdown – very good, good, bad, very bad ]

Prompt if needed: Do you have any health concerns?

5. Do you know what to do if you feel like you need to see a doctor or healthcare professional? [dropdown – Yes/No]

6. Is there anything you wish you could see a doctor or healthcare professional for that you currently do not? [dropdown – Yes/No] and [text box]

If Yes: Would you be interested in being connected to support accessing health care? [dropdown – Yes/No]

7. Medical Health Comments: [text box]

8. Mental Health Comments: [text box]

IMMIGRATION & LEGAL SERVICES

1. Are you aware of when your next immigration court hearing will be? [dropdown – Yes/No/Refuse to Answer]

Inform the child that they can call 1-800-898-7180 or visit EOIR online at https://acis.eoir.justice.gov/es/ and enter their A# for an update on their case. If applicable, note that they can push #2 to hear instructions in Spanish if they call.

If no, check the EOIR website while on the call and provide the child the information on their next immigration court hearing.

If Yes: Is there a plan for how you will attend your court date, for example who will take you and how you will travel there? [dropdown – Yes/No/Don’t Know/Refuse to Answer] [text box]

2. (30-Day Call) If your scheduled immigration court date has passed, did you attend? [dropdown – Yes/No/Don’t Know/Refuse to Answer/Not Applicable]

3. Do you still have your Verification of Release form and/or card? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no, provide the child information on how to request a new form.

4. Have you found an organization or attorney to represent your case? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If No: Would you like assistance finding and accessing legal services? [dropdown – Yes/No]

If Yes:

Organization Name: [text box]

Attorney Name: [text box]

Phone: [text box]

Email: [text box]

5. Comments: [text box]

SAFETY & WELL-BEING

Post-Release

1. Are there times when you do not feel safe, at home, school, or another place? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

2. Is there anything making you feel unsafe? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

3. Are you being made, or have you been made, to do anything you don’t or did not want to do? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

4. Is there anything that happens, or has happened, at home that makes or made you feel uncomfortable? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

5. Are your needs being provided for (food, clothing, medical care, shelter)? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Do you have enough food to eat at home? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Do you get enough sleep? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

6. (30-Day Call) How is your eating and appetite? [dropdown – very good, good, bad, very bad]

If needed: [text box]

7. (30-Day Call) How have you been sleeping at night? [dropdown – very good, good, bad, very bad]

If needed: [text box]

8. (30-Day Call) How have you been adjusting to your home environment? [dropdown –very good, good, bad, very bad]

If needed: [text box]

9. (30-Day Call) Do you participate in any activities at school or in the community? [Yes/No/Don’t Know/Refuse to Answer]

Prompt if needed: Do you have activities, hobbies, or other things that you like to do in your new environment?

If no, please explain: [text box]

10. (30-Day Call) Have you made any friends? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes: Do you get to spend time with them? [dropdown – Yes/No]

If No: Why not? [text box]

11. Have you or anyone else ever been asked to pay fees or wire money for your journey to the U.S. or release from ORR? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Who asked for this money? [text box]

How much did they ask for? [text box]

Did you (or someone else) send it? [dropdown – Yes/No/Refuse to Answer]

What’s the contact information of the person who asked for this money? [text box]

Do you have access to your documents and/or ID? ? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no, please explain: [text box]

Prompt if needed: Has anyone taken your documents or given you a new ID?

12. Has anyone asked to use your ID? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

13. Is there anything else you wanted to share with me? [text box]

14. Is there anything else we can help you or your family with? [text box]

15. Comments on post-release experience: [text box]

WORK

1. Are you working? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes:

Who do you work for/what is the name of your employer? [text box]

What do you do for work? [text box]

On average, how many hours a day are you working? [dropdown - 1-24]

On average, how many days a week are you working? [dropdown – 1-7]

Are you being paid? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes: What do you do with the money? [textbox]

Prompt if needed: Are you expected to give the money to someone else for any reason, for example to pay for transportation, housing, uniforms, getting the job, etc.?

Are you being forced to work? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Are you being forced to pay someone money? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

Is anyone keeping part of your paycheck? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes: Who, if anyone, are you giving part of your paycheck to? [text box]

Is anyone asking you to pay off a debt, rent, or utilities? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If Yes: Who, if anyone, are you paying debt, rent, or utilities to? [text box]

2. Are you or your family now required to financially contribute to the sponsor’s household? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

3. Comments: [text box]

In-Care

1. Thinking about your time in ORR care, how was your experience at your ORR shelter program(s)?

Positive feedback: [text box]

Negative feedback: [text box]

2. How would you rate your experience at your program(s)? Would you say it was a very good, good, bad, or very bad experience? [dropdown – very good, good, bad, very bad]

3. Was there anything that happened at your program(s) that made you feel uncomfortable? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

4. Did anything make you feel unsafe at your program(s)? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

5. While you were in your program(s) did anyone ask to take pictures of you or with you, other than your photo for the Portal record when you arrived?[dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

6. While you were in your program(s), did anyone touch you in a sexual way, have you touch their body in a sexual way, speak to you in a sexual way, or make you uncomfortable with their sexual language? Did anyone ever threaten you to try to make you do something sexual? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

7. Did you feel that the shelter staff showed you respect? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If no, please explain: [text box]

8. Is there anyone you are keeping in contact with from the shelter? [dropdown – Yes/No/Don’t Know/Refuse to Answer]

If yes, please explain: [text box]

9. Comments: [text box]

Post-Call Assessment & Outcomes

Virtual Check-In Type: [dropdown] 7-Day Virtual Check-In 14-Day Virtual Check-In 30-Day Virtual Check-In Filling out for PRS Level 2 Case Filling out for PRS Level 3 Case
Caller Name: [auto-populate]	Attempt Date/Time: [text box]
Attempt Number: [auto-populate]	Phone Disconnected? [dropdown – Yes/No]
Sponsor’s Participation: [Dropdown] Reached and participated Reached and declined to participate Not reached	Child’s Participation: [Dropdown] Reached and participated alone Reached and participated with someone else around Reached and declined to participate Not reached
Methods of Attempt:
¨ Called Child and Sponsor’s primary phone	¨ Sent WhatsApp or text message
¨ Called Child and Sponsor's backup phone	¨ Sent email
¨ Called number(s) in Care Plan	¨ Sent letter
¨ Called number(s) in Home Country	¨ In-person visit
¨ Left voicemail	¨ Other
If Other, specify: [text box]
Does the child appear to be in immediate danger? [dropdown – Yes/No]
Should the child or sponsor be assessed for additional post-release services? [dropdown – Yes/No]
Was a safety concern about the child’s time in ORR care identified? [dropdown – Yes/No]
Post-Call Action Taken:
¨ Elevated to Supervisor
¨ Referral to ORR National Call Center	¨ Notification of Concern
¨ Referral to NCMEC	¨ Referral to OTIP
¨ Report to Local Law Enforcement	¨ Sponsor Flag
¨ Report to Sexual Abuse Hotline	¨ Address Flag
¨ Report to Child Abuse Hotline (State Licensing)	¨ Household Member Flag
¨ Referral to FFS	¨ Alternate Caregiver Flag
¨ Contact Child’s Attorney	¨ Contact Child’s Child Advocate
Reason for Elevation (if applicable):
¨ Child Labor/Labor Trafficking	¨ UC Criminal Activity
¨ Sex Trafficking	¨ UC Death
¨ Neglect/Abandonment	¨ UC Medical/Mental Health Issue
¨ Physical Abuse	¨ Fraud Against Sponsor
¨ Sexual Abuse/Harassment	¨ Fraudulent Sponsor
¨ Sponsor Criminal Activity	¨ Other
Comments: Note: If applicable, include the referral or case number for any reports, such as to law enforcement or Child Protective Services. [text box]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: This information collection allows ORR to document the outcome of calls made to UC and their sponsors after release to ensure the child is safe and refer the sponsor to additional resources as needed. Public reporting burden for this collection of information is estimated to average 0.25 hours each for sponsors and children, and 0.58 hours for PRS providers 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 (8 U.S.C. § 1232). 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].

R-6 | Version 3 Page 1 of 25

Revised MM/DD/20YY