S-6 Home Study Assessment - Word Version

OMB 0970-0553 [Valid through 02/28/2021]

ORR/DCS Home Study Report

Section A: UC IDENTIFYING INFORMATION
Name:		AKA:		A#:
Date of Birth:	Age:		Place of Birth: El Salvador Honduras Ecuador Guatemala Mexico India Other:      		Sex: M F

Section B: SPONSOR IDENTIFYING INFORMATION
Name:	Date of Birth:		Sex: M F
Place of Birth: El Salvador Honduras Ecuador Guatemala Mexico India Other:      	Marital Status: Single Married since      		Category of Sponsor: Category 1 Category 2 Category 3 Relationship to UC: ___________________
Home Address:		Contact Number(s): (h) (w) (c)

Section C: CASE INFORMATION
Date of Most Recent ORR Placement:	Current Care provider:	Care Provider Contact:
Date Referred for Home Study:	Date Home Visit Completed:	Date Report Completed:
Home Study Agency:	Home Study Case Worker:	Home Study Contact Number:

Section D: REASON FOR REFERRAL

UC meets the following referral criteria: ¹

Potential sponsor clearly presents a risk of abuse, maltreatment, exploitation, or trafficking to the UC based on all available objective evidence;

UC has been identified as a victim of a severe form of trafficking in persons;

UC has been a victim of physical or sexual abuse under circumstances that indicate that the UC’s health or welfare has been significantly harmed or threatened;

UC has special needs, with a disability as defined in section 3 of the Americans with Disabilities Act of 1990, 42 U.S.C. § 12102(1):

• A physical or mental impairment that substantially limits one or more major life activities of such individual

• A record of such an impairment

• Being regarded as having such an impairment

UC is under the age of 12 and sponsor is a Category 3²

Sponsor is unrelated and is seeking to sponsor multiple UC³

Sponsor is unrelated and has previously sponsored another UC⁴

Other concerns

Brief explanation of why the UC meets the referral criteria and the general concerns to be investigated during the Home Study:

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section E: UC BACKGROUND/OVERVIEW

1. UC Background Information (For example: who was UC raised by, description of their relationship with that person, education, any presenting problems/challenges, reasons UC migrated to the U.S., and any previous time spent in ORR care).

__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Significant Incident Reports (SIRs) while in ORR/DCS shelter care. Please list with include dates and brief description.

________________________________________________________________

______________________________________________________________________________________________________________________________________

3. Does the UC have special needs? (include physical and mental health needs- include diagnosis and prescribed medication).

_________________________________________________________________________________________________________________________________________________________________________________________________________

4. UC’s understanding of the following U.S. Laws:

• Employment

The UC was provided with psycho-education on U.S. laws in regards to employment. The UC was informed about age and document requirements for work, school work permits, and employee rights.

• Education

The UC was provided with psycho-education on school enrollment, parent’s rights to contact the school and student’s rights to seek services.

• Child abuse/neglect

The UC was provided with psycho-education on the four types of abuse (sexual, physical, emotional, and neglect). The UC was also informed about the confidentiality of reporting child abuse and the different locations where it could be reported (e.g. police station, school, fire department, medical clinic); in addition to mandated reporters (therapist, social worker, counselor, and teacher).

5. Location of UC’s parents and other family in the U.S, and description of the UC’s relationship with biological family (provide the location of other family members in the U.S. and their involvement with UC):

_________________________________________________________________________________________________________________________________________________________________________________________________________

6. UC’s history of criminal charges, substance abuse, or gang involvement, and the UC’s plan to address past behaviors:

_________________________________________________________________________________________________________________________________________________________________________________________________________

7. How does the UC know the Sponsor? Please include both the perspective by the UC and Sponsor. _________________________________________________________________________________________________________________________________________________________________________________________________________

8. Is the UC aware of other individuals living in the sponsor’s home? If so, what is their relationship? _________________________________________________________________________________________________________________________________________________________________________________________________________

9. Does the UC know how the Sponsor disciplines children? Explain. _________________________________________________________________________________________________________________________________________________________________________________________________________

10. Does the UC feel safe moving in with the Sponsor?

_________________________________________________________________________________________________________________________________________________________________________________________________________

11. What are the UC’s expectation of reunification with the Sponsor (including home environment, lifestyle, chores, and education opportunities):

_________________________________________________________________________________________________________________________________________________________________________________________________________

12. Does the UC feel that there are any services that would be helpful to him/her post-release?

____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

13. Note Section for Additional Information from Interview with UC

_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Section F: SPONSOR BACKGROUND/OVERVIEW

1. Sponsor’s background (Include the Sponsor’s immigration process, legal status, education, length of time in the U.S., etc.) __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

2. Sponsor’s current functioning:

• Major Medical issues (include diagnosis and prescribed medication)

N/A ______________________________________________________________________________________________________________________

• Mental health issues (include diagnosis and prescribed medication)

N/A ________________________________________________________________________________________________________________________________

• Substance use

N/A ________________________________________________________________________________________________________________________________

3. Coping mechanisms as observed during Home Study (include Sponsor’s interests, personality, strength, and weakness):

___________________________________________________________________

___________________________________________________________________

4. Significant relationships- including with a spouse or domestic partner, and other formal and informal support systems and how the Sponsor intends to use supports for him/herself as well as the UC;

___________________________________________________________________

___________________________________________________________________

5. Sponsor’s understanding of the following U.S. Laws:

• Employment

The Sponsor was provided with psycho-education on U.S. laws in regards to employment. The Sponsor was informed about age and document requirements for work, school work permits, and employee rights.

• Education

The Sponsor was provided with psycho-education on school enrollment, sponsor’s rights to contact the school and student’s rights to seek services.

• Child abuse/neglect

The Sponsor was provided with psycho-education on the four types of abuse (sexual, physical, emotional, and neglect). The Sponsor was also informed about the confidentiality of reporting child abuse and the different locations where it could be reported (e.g. police station, school, fire department, medical clinic); in addition to mandated reporters (therapist, social worker, counselor, and teacher).

6. Language proficiency in English and UC’s native language.

_______________________________________________________________________________________________________________________________

Section G: SPONSOR’S RELATIONSHIP to UC and MOTIVATION

1. Nature and the extent of the Sponsor’s relationship with the UC and the UC’s immediate family, including frequency and quality of contacts, include the last face to face and phone contact between the sponsor and the UC.

______________________________________________________________________________________________________________________________________

2. Location of the Sponsor’s family members in the U.S. and their relationship and involvement with the UC.

N/A – no others family members in the U.S. per Sponsor

______________________________________________________________________________________________________________________________________

3. Sponsors awareness and involvement in UC’s plan of migration to the USA.

N/A –per sponsor and UC, sponsor was unaware of UC’s travel/plans, etc.

______________________________________________________________________________________________________________________________________

4. Sponsor’s awareness of the details around the UC’s journey including whether there was a traveling fee or debt; when, how and where the UC was apprehended by U.S. immigration authorities; and whether the UC experienced any trauma along the way.

______________________________________________________________________________________________________________________________________

5. Sponsor’s reasons for wanting to care for the UC.

______________________________________________________________________________________________________________________________________

6. Any prior Sponsorship applications to Sponsor previously identified UC; state UC name, date of birth, his/her relationship to Sponsor, Alien number, location and current welfare for each UC the sponsor has applied to sponsor.

N/A

______________________________________________________________________________________________________________________________________

Section H: SPONSOR’S PARENTING/SPONSORSHIP

General Parenting

1. Parenting skills and / abilities, nature and extent of previous experience with child supervision, including discipline, parenting style and designation of household responsibilities/chores. Include any community parenting resources that the Sponsor has identified.

______________________________________________________________________________________________________________________________________

2. What is the sponsor’s supervision plan? If the sponsor is not available to supervise the UC, who will provide supervision in the sponsor’s absence?

______________________________________________________________________________________________________________________________________

3. Care of any children currently in the home – school enrollment, mental health/behavioral issues, relationships, etc.

N/A - no children in home

______________________________________________________________________________________________________________________________________

4. What are the sponsor’s discipline methods? What consequences does the sponsor issue with the children currently in the home (if applicable)? ______________________________________________________________________________________________________________________________________

5. Any anticipated significant life changes in the near future and how these changes may affect the Sponsor’s ability to care for the UC (i.e., change in residence, marriage, divorce).

N/A - no anticipated changes ______________________________________________________________________________________________________________________________________

6. Sponsor’s understanding of UC’s current behavior, history of criminal charges, substance abuse, or gang involvement:

_________________________________________________________________________________________________________________________________________________________________________________________________________

7. Sponsor’s plans to address the UC’s past behaviors and current needs, including special needs:

_________________________________________________________________________________________________________________________________________________________________________________________________________

Child Welfare

8. Challenges the Sponsor foresees in parenting a child whom he/she has been separated from or has never parented before, and how to overcome challenges.

______________________________________________________________________________________________________________________________________

9. Sponsor’s understanding of the dynamics of separation, grief and loss and how the Sponsor will help the UC cope with such emotions.

______________________________________________________________________________________________________________________________________

Sponsor was provided with psycho-education on further implications on a child’s behaviors after years of separation from parents and other family members.

10. Sponsor’s understanding of the laws and dynamics of child abuse and neglect and the sponsor’s ability to parent a child who may have been abused or neglected.

______________________________________________________________________________________________________________________________________

Sponsor was provided with psycho-education on the four types of abuse (sexual, physical, emotional, and neglect) and laws.

Education

11. Sponsor’s understanding of the laws surrounding education, educational opportunities, and plans for enrollment (list a potential school), including after school supervision.

______________________________________________________________________________________________________________________________________

Sponsor was provided with psycho-education on school enrollment, truancy laws, parents and legal guardian’s rights to contact the school and student’s rights to seek services.

12. How equipped does the Sponsor feel in order to advocate for the UC to receive necessary services:

Highly equipped; can identify specific services and locations

Moderately equipped; has general knowledge but requires referrals for community services for the following areas: (please specify)_________

Not sufficiently equipped

Legal

13. Did the Sponsor attend a LOPC presentation? Yes No

14. Sponsor’s plan to ensure the UC’s attendance at all immigration court proceedings and comply with DHS requirements.

______________________________________________________________________________________________________________________________________

15. Sponsor’s plans for legal representation for the UC.

______________________________________________________________________________________________________________________________________

16. Immigration attorney representing the UC

N/A - No Attorney

• Name(s) of the attorney(s)

     

• Phone number(s)

     

• Address

     

Section I: HOUSEHOLD MEMBERS

General

• Were household members (including children) interviewed separately from the Sponsor? Yes No

Household member #1:

Name	DOB	Age	Sex	Relationship to Sponsor	Relationship to UC	Is the Sponsor Financially Responsible for this Individual?

Present during home visit? Yes No

If ‘No’, document attempts to contact: ______________________________________________________________________________________________________________________________________

Comments (include members’ perspective on the UC coming to live in the home, member’s role in the UC’s life):

________________________________________________________________________________________________________________________________________

Household member #2:

Name	DOB	Age	Sex	Relationship to Sponsor	Relationship to UC	Is the Sponsor Financially Responsible for this Individual?

Present during home visit? Yes No

If ‘No’, document attempts to contact: ______________________________________________________________________________________________________________________________________

Comments (include members’ perspective on the UC coming to live in the home, member’s role in the UC’s life):

____________________________________________________________________

____________________________________________________________________

Household member #3:

Name	DOB	Age	Sex	Relationship to Sponsor	Relationship to UC	Is the Sponsor Financially Responsible for this Individual?

Present during home visit? Yes No

If ‘No’, document attempts to contact: ______________________________________________________________________________________________________________________________________

Comments (include members’ perspective on the UC coming to live in the home, member’s role in the UC’s life):

________________________________________________________________________________________________________________________________________

Review of Background Checks

1. OSSI clearance

All Adults in the home submitted fingerprints for

YES

NO; Explanation:

RESULTS RECEIVED RESULTS PENDING

2. CA/N check

Submitted for Sponsor and/or other Adults in the home

YES

NO; Explanation:

RESULTS RECEIVED RESULTS PENDING

Use additional pages for more family members

Section J: HOME AND COMMUNITY

Physical Environment

1. Type of housing

Single Family Home Townhome Apartment

Mobile Home Other ____________

2. Does the Sponsor Own or Rent?

Own Rent

3. If Renting: has the landlord approved the UC living in the residence?

Approved – sponsor informed landlord and no concerns reported

Unknown status – sponsor has not informed landlord. Note reason for not informing landlord and plan to confirm approval: ____________________________________

How long has the Sponsor resided at this residence? __________________

4. Internal:

Do any household members smoke? Yes No Yes No	Is smoking allowed in the house? Yes No
Are there weapons present in the home? Yes No If Yes, are the weapons and ammunition kept separately in locked areas? Yes No	Is there a functional smoke detector: Yes No
Are there pets in the home? Yes No If Yes, List:	Do pets meet local safety requirements (vaccinations, vicious animal restrictions, etc.)? Yes No

5. External:

Outside Space: Check all that apply

Patio Hot Tub Fenced Yard Detached Garage Play Equipment Porch Deck Shed/Barn Attached Garage Pool/Pond/Lake Fenced and Locked Gate Handicapped Accessible Other (specify): ________________________________________

6. If the home has a pool/pond/lake, please explain how Sponsor will ensure safety/supervision of tender age child around water source: ______________________________________________________________________________________________________________________________________

7. Sleeping arrangements for each family member (include room, floor/level, and type of bed)

Family Member	Age	Windows	Bedroom Number	Type of bed

8. Any evidence that individuals other than those listed in the family reunification packet as living in the home residence?

Yes: _________________________________________________________________

N/A – no others noted to be living in home

9. Is there anything in the home that raises a concern for the UC’s welfare and safety? If so can it be resolved?

________________________________________________________________________________________________________________________________________________________________

Transportation

Vehicles: One Car Two Cars Truck Van Recreation Vehicle Motorcycle Other (specify) ___________________________
Are vehicles in running condition? Yes No If no, explain:
Was proof of insurance provided for all operational vehicles? Yes No
Is the residence on a city bus line or other public transportation? Yes No	If yes, distance to nearest stop:   
Describe alternative transportation plan if family does not own an operating vehicle or live on a bus line:      

Community Overview

10. Briefly describe the community in which the home is located. Include information regarding the type of neighborhood (rural, urban, residential, industrial, etc.).

_________________________________________________________________________________________________________________________________________________________________________________________________________

Schools:

Name	Street	City, State	Zip	Phone Number

Emergency Resources:

Name	Street	City, State	Zip	Phone Number

Medical/Health Clinics:

Name	Street	City, State	Zip	Phone Number

Recreational Locations, including religious facilities, shopping centers, libraries, parks, etc.:

Name	Street	City, State	Zip	Phone Number

Section K: FINANCIAL

1. Employment Status:

Unemployed

Part-time

Full-time:

Other:     

2. Employer: _______________________

Self-employed. Please specify: _____________________

Does applicant operate a business from the residence? Yes No
If Yes:	Is business a Child Day Care? Yes No	Is business an Adult Day Care or Rooming House? Yes No
If other than child or adult day care or rooming house, describe type of business:      
If applicable, describe impact of home business on the plan to Sponsor the UC:      

3. Length of time employed in current job: ________________

N/A

4. Working hours_______________________

N/A

5. Prior employment? Yes No If Yes, How long? _____________

6. Total annual take-home income of sponsor

_________________

7. Sources of income

Employment Other:     

8. Budget- assets/liabilities and income/expenses

_________________________________________________________________________________________________________________________________________________________________________________________________________

9. Sponsor’s plan to handle additional financial burden of caring for the UC

______________________________________________________________________________________________________________________________________

Section L: SUMMARY

Family Strengths and Needs

1. Describe the Sponsor’s ability to provide and maintain a safe, stable and appropriate home environment.

______________________________________________________________________________________________________________________________________

2. Describe the Sponsor’s ability to care for the UC’s well-being and safety (parenting, supervision, financial).

______________________________________________________________________________________________________________________________________

3. Describe the Sponsor’s support system (include his/her ability to utilize community services).

______________________________________________________________________________________________________________________________________

4. List the risk and protective factors to UC’s reunification with Sponsor:

Risk Factors	Protective Factors

5. Resources that have already been identified by the Sponsor:

______________________________________________________________________________________________________________________________________

Section M: RECOMMENDATION FOR RELEASE

Positive Recommendation

Please provide objective examples which support this recommendation

____________________________________________________________________________________________________________________________________________

Negative Recommendation

Please provide objective examples which support this recommendation

____________________________________________________________________________________________________________________________________________

Please provide any recommended action steps for the Sponsor which would potentially change this recommendation from negative to positive.

__________________________________________________________________________________________________________________________________________________________________________________________________________________

Case Worker Signature:

Date:

Supervisor Signature:

Date:

Date Submitted to ORR Shelter Facility

1 The first four categories are outlined as mandated home studies in the TVPRA 2008, Section 235

2 July 1, 2015 Pilot Program/Policy Change

3 July 27, 2015 Policy Change

4 July 27, 2015 Policy Change

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow home study providers to document their assessment of a potential sponsor after performing a home site visit. 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, and Trafficking Victims Protection Reauthorization Act, 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].