Form P-12C Program Entity

Placement and Transfer of Unaccompanied Children into ORR Care Provider Facilities

P-12C Program Entity

Program Entity (Form P-12C)

OMB: 0970-0554

Document [docx]
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Program Entity (Form P-12C)

DETAILS


Program Overview



Program Status


Program Name AKA






Type


Program ID






Address


Country






Street


City






State


Zip/Postal Code






ACF Region


Within ORR Network?

Yes/No





FFS Region


VOLAG Grantee?

Yes/No





UC Drop-Off Information


URM Program?

Yes/No





Maximum Months Pregnant


Confirmed? ¨




Points of Contact



CEO


CEO Email








Phone






Program Director








Intakes Primary Contact


Intake Primary Contact Email








Intakes Primary Contact Phone






Program Medical Team Email


FFS Email




Stakeholder Information



Child Advocate


Legal Service Provider






FOJC






Influx and Variance Bed Capacity



Undelivered Warm Status


Delivered Variance Beds






Undelivered Reserve Status


Undelivered Variance Beds




License



Licensed?

Yes/No

License Issued Date






Licensing Entity


License Expired Date






License Type


Copy of Lease Uploaded? ¨






Licensing POC #1


Licensing POC #1 Email








Licensing POC #1 Phone






Licensing POC #2


Licensing POC #2 Email








Licensing POC #2 Phone






Licensing POC #3


Licensing POC #3 Email








Licensing POC #3 Phone




Grant



Grant Number


Secondary Grant Number






Current Grant Project Start Date


Current Grant Project End Date






Current Grant Budget Start Date


Current Grant Budget End Date






Initial Grant Award Date


Closure Date






Initial UC Placement Received Date


Closure Date Reason




Stop Placement



Stop Placement (Initial)

Yes/No

Anticipated End Date (Initial)






Stop Placement Reason (Initial)


Start Date (Initial)








End Date (Initial)






Stop Placement (Transfer)

Yes/No

Anticipated End Date (Transfer)






Stop Placement Reason (Transfer)


Start Date (Transfer)








End Date (Transfer)




Monitoring Details



Last Monitoring Date


First Admitted Date






Due Date for Next Monitoring Visit


Number of Sites






Monitoring Schedule Notes





System Information


Program Legacy ID


Facility Legacy ID




RELATED


Entity Team


Team Member

Member Role

Entity Access Level

Entry Access Level

UC Access Level






















Facility Information


Title

Original Document Name

Record Type

Document Type

Description

Date Received

Created By

Created Date


































Operational Information


Title

Original Document Name

Record Type

Document Type

Description

Date Received

Created By

Created Date


































Compliance Information


Title

Original Document Name

Record Type

Document Type

Description

Date Received

Created By

Created Date


































Entity History


Date

Field

User

Original Value

New Value






















Beds


Bed Name

Proposed Delivery Date

Actual Delivery Date

Last Modified Date

Last Update by Alias






















Funded Capacity Manager


How many delivered male beds?


How many undelivered male beds?






How many delivered female beds?


How many undelivered female beds?



OMB 0970-0554 [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 allow ORR to track certain information related to its care provider programs, such as location, contact information, state licensure, grant information, and monitoring. Public reporting burden for this collection of information is estimated to average 0.17 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].

P-12C [Revised MM/DD/YYYY]

Shape1

Dropdown Options

Program Status

  • Active

  • Inactive

  • Draft

Type

  • Influx Care Facility

  • Long Term Foster Care

  • LTFC – Community Placements

  • LTFC – Group Home

  • Residential Treatment Center

  • Secure

  • Shelter

  • Staff Secure

  • Therapeutic Group Home

  • Therapeutic Staff Secure

  • Therapeutic Foster Care

  • Emergency Intake Sites

  • Other

Country

List of all countries

State

List of all states and the District of Columbia

ACF Region

  • 1

  • 2

  • 3

  • 4

  • 5

  • 6

  • 7

  • 8

  • 9

  • 10

FFS Region

  • Arizona

  • Central Texas

  • Houston/El Paso

  • Mid-Atlantic

  • Mid-West

  • North East

  • Rio Grande Valley

  • South East

  • Special Population

  • West Coast

Maximum Months Pregnant

  • Month 1: Weeks 1 to 4

  • Month 2: Weeks 5 o 8

  • Month 3: Weeks 9 to 13

  • Month 4: Weeks 14 to 17

  • Month 5: Weeks 18 to 22

  • Month 6: Weeks 23 to 27

  • Month 7: Weeks 28 to 31

  • Month 8: Weeks 32 to 35

  • Month 9: Weeks 36 to 40

Licensing Entity

List of licensing entities for all states in which ORR operates care provider programs

License Type

List of all license types offered by the licensing entities available under the Licensing Entity Field, as applicable to ORR care provider programs

Stop Placement (Initial) and Stop Placement (Transfer)

  • Imminent risk of harm to or safety of UC

  • Imminent risk of harm to or safety of staff

  • Law enforcement agency recommendations to cease new referrals

  • Identified risk is not related to one staff or incident, and cannot be corrected by the corrective action

  • Active CPS licensing investigation involving staff, UC or both

  • Grantee repeated non-compliance with ORR policies and procedures which impacts service to UC

  • Shortage of staff

  • Staff related incident

  • Consistent pattern of UC running away

  • Affected by natural disasters/evacuation

  • Power outage

  • Fire incident

  • Isolation/Medical Concerns

  • Request by the facility

  • Other (provide details)

Team Member Role

This is a global picklist used across multiple forms that contains all roles. Appearance of a role on this list does not mean that role will be granted access to this form.

  • Assistant Program Director

  • Attorney

  • Case Coordinator

  • Case Manager

  • Child Advocate Contact

  • Clinician

  • Contractor Field Specialist

  • DHUC Medical Team Member

  • DHUC Quality Assurance Specialist

  • Direct Operations Coordinator

  • DOJ/FBI

  • Federal Field Specialist

  • HHS OIG

  • HS/PRS Primary Providers

  • ICE FOJC

  • Influx POC

  • Intakes Backup Contact

  • Intakes Contact

  • Lead Case Manager

  • Lead Clinician

  • Legal Service Provider

  • LNO

  • Medical Coordinator

  • Medical Service Director

  • On-site Health Care Provider

  • ORR Compliance Team

  • Program Director

  • Program Support Center

  • Project Officer

  • PSA Compliance Manager

  • PSA Program Specialist

  • PSA Team

  • Regional Director

  • Registered Nurse

  • Senior Advisor for Child Well-Being & Safety

  • Shift Supervisor

  • Supervisory Case Coordinator

  • Supervisory FFS

  • Supervisory Project Officer

  • Temporary

  • VOLAG User

  • Program Support Staff

Entity Access Level

  • Read Only

  • Read/Write

Entry Access Level

  • Read Only

  • Read/Write

  • No Access

UC Access Level

  • Read Only

  • Read/Write

  • No Access

Record Type/Document Type

Available Document Types are dependent upon what Record Type is selected.

  • Facility

  • Other

  • Facility Intake List

  • Program Brief

  • Program Lease

  • Signed Cooperative Agreement

  • State Licensure

  • Fire Inspection

  • Emergency/Evacuation Plan

  • Facility Floor Plan

  • Operational

  • Other

  • Grantee Daily Schedule

  • Internal SOPs

  • Staff Training Curriculum

  • Educational Curriculum

  • Vocational Curriculum

  • Food Menu

  • UC Handbook/Orientation

  • Prevention of Sexual Abuse/Harassment SOPs

  • Organizational Chart

  • Compliance

  • Other

  • ORR Closed Corrective Action

  • ORR Closed Monitoring Report

  • ORR Site Visit Report

  • Program Licensing Investigation

  • PSA Audit


File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorHerboldsheimer, Shannon (ACF)
File Modified0000-00-00
File Created2024-08-01

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