Form S-18 Admission

OMB# 0970-0553

UAC Basic Information

First Name:

(Auto-populated; editable *

Last Name:

(Auto-populated; editable *

DOB:

(Auto-populated; editable <POP-UP CALENDAR>)* 

AKA:

(Auto-populated; editable)

A Number:

(Auto-populated; not editable)

 

Sex:

(Auto-populated; editable <Dropdown Menu> (-Select One - Male; Female) )*

LOS:

(System Generated)

Country of Birth:

(Auto-populated; editable <Dropdown Menu> See Reference Table 1 “Countries” for complete list of options)

Age:

(System Generated)

Admitted Date:

(System Generated)

Program Type:

(Auto-populated; not editable)

 

Program:

(Auto-populated; not editable: “Program Names” for complete list of options)

Physical Location of the Child:

(Auto populate – Source: UC Portal Discharge Tab) See “Location of Child Appendix – UAC Case Status”

UAC Photo Path:

System Generated <File Upload Path>

 

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow case managers to document the UAC’s initial needs, functioning, and history. Other instruments are also accessible from within the admission instrument, such as transfer requests, travel requests, and various child assessments. Public reporting burden for this collection of information is estimated to average 0.33 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].

Admission
Status:	<DROPDOWN MENU:> (-- Select Status -- Admit; Pending; Cancel)
By selecting 'Yes' in this field, you are confirmed that you have verified that the information provided above exactly matches the information officially documented by the Department of Homeland Security. Once 'Yes' is selected, this child's biographical information will be shared with the Public Health Services (PHS). If 'Yes' is not selected, the information will not be sent to PHS.			q Yes q No
Admission Date:	(editable <POP-UP CALENDAR> MM/DD/YYYY)	Admission Time:	(editable <POP-UP CLOCK> HH:MM; AM/PM)

Reference Table 1: Country of Birth

<Dropdown Menu> (-Select Country- Afghanistan; Aland Islands; Albania; Algeria; American Samoa; Andorra; Angola; Anguilla; Antarctica; Antigua and Barbuda; Arabian Peninsula; Argentina; Armenia; Aruba; Australia; Austria; Azerbaijan; Bahamas; Bahrain; Bangladesh; Barbados; Belarus; Belgium; Belize; Benin; Bermuda; Bhutan; Bolivia; Bonaire, Sint Eustatius and Saba; Bosnia and Herzegovina; Botswana; Bouvet Island; Brazil; British Virgin Islands; Brunei; Bulgaria; Burkina Faso; Burundi; Cambodia; Cameroon; Canada; Cape Verde; Cayman Islands; Central African Republic; Chad; Chile; China; Chinese Taipei; Christmas Island; Cocos Islands; Colombia; Comoro Islands; Congo; Cook Islands; Costa Rica; Cote D'Ivoire; Croatia; Cuba; Curaçao; Cyprus; Czech Republic; Czechoslovakia; Dem Rep Of The Congo; Denmark; Djibouti; Dominica; Dominican Republic; East Timor; Ecuador; Egypt; El Salvador; Equatorial Guinea; Eritrea; Estonia; Ethiopia; Falkland Islands; Faroe Islands; Fiji; Finland; France; French Guiana; French Polynesia; French Southern And Antarctic; Gabon; Gambia; Georgia; Germany; Ghana; Gibraltar; Greece; Greenland; Grenada; Guadeloupe; Guam; Guatemala; Guernsey; Guinea; Guinea-Bissau; Guyana; Haiti; Heard Island and McDonald Islands; Holy See; Honduras; Hong Kong; Hungary; Iceland; India; Indonesia; Iran; Iraq; Ireland; Isle of Man; Israel; Italy; Ivory Coast; Jamaica; Japan; Jersey; Jordan; Kazakhstan; Kenya; Kiribati; Korea; Kosovo; Kuwait; Kyrgyzstan; Laos; Latvia; Lebanon; Lesotho; Liberia; Libya; Liechtenstein; Lithuania; Luxembourg; Macao; Macedonia; Madagascar; Malawi; Malaysia; Maldives; Mali; Malta; Mariana Islands; Northern Maritime; Marshall Islands; Martinique; Mauritania; Mauritius; Mayotte; Mexico; Micronesia; Moldova; Monaco; Mongolia; Montenegro; Montserrat; Morocco; Mozambique; Myanmar; Namibia; Nauru; Nepal; Netherlands; Netherlands Antilles; New Caledonia; New Zealand; Nicaragua; Niger; Nigeria; Niue; Norfolk Island; North Korea; Norway; Oman; Pakistan; Palau; Palestinian Territory, Occupied; Panama; Papua New Guinea; Paraguay; Peru; Philippines; Pitcairn Islands; Poland; Portugal; Puerto Rico; Qatar; Reunion; Romania; Russia; Rwanda; ST. Pierre And Miquelon; Saint Barthelemy; Saint Kitts and Nevis; Saint Lucia; Saint Martin (French part); Saint Vincent And the Grenadines; Samoa; San Marino; Sao Tome and Principe; Saudi Arabia; Senegal; Serbia; Seychelles; Sierra Leone; Singapore; Sint Maarten (Dutch part); Slovakia; Slovenia; Solomon Islands; Somalia; South Africa; South Georgia and the South Sandwich Islands; South Korea; South Sudan; Spain; Sri Lanka; St. Helena; Sudan; Suriname; Svalbard and Jan Mayen; Swaziland; Sweden; Switzerland; Syria; Taiwan; Tajikistan; Tanzania; Thailand; Togo; Tokelau; Tonga; Trinidad and Tobago; Tunisia; Turkey; Turkmenistan; Turks And Caicos Islands; Tuvalu; USSR; Uganda; Ukraine; United Arab Emirates; United Kingdom; United States of America; Unknown; Uruguay; Uzbekistan; Vanuatu; Venezuela; Vietnam; Virgin Islands, U.S.; Wallis And Futuna Islands; West Bank; Western Sahara; Western Samoa; Yemen; Yugoslavia; Zambia; Zimbabwe)

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S-18 | Version #.#

Valid through MM/DD/YYYY