Form S-9 Assessment for Risk

OMB 0970-0XXX; Valid Through MM/DD/YYYY

Administration for Children and Families

Office of Refugee Resettlement

of Refugee Resettlement

Administration for Children & Families

Office of Refugee Resettlement

Assessment for Risk (S-9)

UAC Portal version with integrated UC Path features

UAC Basic Information
	First Name:	(Auto Populate)	AKA:	(Auto Populate)
	Last Name:	(Auto Populate)	Status:	(Auto Populate)
	Date of Birth:	(Auto Populate)	Admitted Date:	(Auto Populate)
	A#:	(Auto Populate)	Length of Stay:	System Generated
	Country of Birth:	(Auto Populate)	Current Program:	(Auto Populate)
	Sex:	(Auto Populate)	Portal ID:	(Auto Populate)
	Physical Location of the Child:		(Auto populate – Source UAC Portal Discharge Tab)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to reduce the risk that a child or youth is sexually abused or abuses someone else while in ORR custody through assessment by qualified care provider staff. 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].

Assessment for Risk INSTRUCTIONS: To comply with requirements of the ORR Standards to Prevent, Detect, and Respond to Sexual Abuse and Sexual Harassment Involving Unaccompanied Children (45 C.F.R. 411.41 – 42), a care provider facility Clinician or qualified Case Manager must complete the Assessment for Risk in the ORR database within 72 hours of a child or youth’s admission. Clinicians or qualified Case Managers take into account the minimally required criteria at 45 CFR 411.41(b) in completing this assessment. This assessment must be updated every 30 days. The purpose of the assessment is to identify risk factors for potential sexual victimization or potential to abuse others so early intervention can mitigate any potential risks if the child is demonstrating concerning behavior toward others and/or provide the child with appropriate therapy/treatment. Although the assessment presents a specific list of questions, the Clinician or Qualified Case Manager is expected to draw upon his/her professional training to obtain any additional information that may contribute to a thorough assessment. The assessment includes questions that the Clinician or Qualified Case Manager obtains from the child or youth as well as questions that the Clinician or Qualified Case Manager must answer based on his/her professional assessment of the individual case. Assessment Status: SYSTEM GENERATED (Pending; Complete; Submitted)
Child’s Preferred Language	(Auto-Populate; Source Initial Intakes Assessment S-8)
Other Languages Spoken by the Child:	(Auto-Populate; Source: Initial Intakes Assessment S-8)
Assessment for Risk Conducted in what language:	<Dropdown Menu> (-Select Language- See Reference Table 1 – Language)

INFORMATION CLINICIANS OR QUALIFIED CASE MANAGERS OBTAIN FROM CHILD OR YOUTH

Do you feel safe in your current room assignment or if not yet assigned, do you have any concerns about being assigned a room that you’d like to talk about?

1 Yes 1 No

If No, please explain

(Open Text)

Has anyone made any comments to you about your body, clothes, or appearance that made you feel uncomfortable , threatened, or unsafe at this facility?

1 Yes 1 No

If Yes, explain:

(Open Text)

NOTE: The following question is asked in accordance with the requirements of 45 CFR 411.41(b): In order to keep you safe, it’s important that we identify any factors that might make you more vulnerable for potential sexual victimization or abuse by others. We’re asking this so we can develop appropriate interventions and safety measures. Some examples of relevant risk factors may include: if you have had any past experiences of sexual abuse or victimization, your physical size and stature, your age, your own perception of your vulnerability, or any non-conforming appearance or mannerisms. Do you have any concerns about this you’d like to share?

1 Yes 1 No  1 Decline to Answer

If Yes, explain:

(Open Text)

Ask whether the child or youth would rather be housed with boys or girls?

1 Housed with Boys

1 Housed with Girls

1 No Preference

Ask whether the child or youth would rather have a female or male staff member conduct a pat down search if one is necessary:

1 Male Staff

1 Female Staff

1 No Preference

Is there anything else I should know about who you are and how you identify?

1 Yes 1 No 1 Decline to Answer

If Yes, explain:

(Open Text)

Is there something that you think we can do to help you feel safe and comfortable while you are here?

1 Yes 1 Not at this time

If Yes, explain:

(Open Text)

The remaining questions in this section should only be asked if the child is aged 10 or older.

Have you had any sexual experiences?

1 Yes 1 No 1 Decline to Answer

1 Decline to Answer, Explain:

(Open Text)

1 Yes, if yes, when you have sex, who do you have sex with?

1 With males only 1 With females only 1 With both males and females 1 Decline to Answer1 Other, Specify:

Specify:

(Open Text)

If Yes, Approximate date of last sexual encounter:

<Pop-Up Calendar> MM/DD/YYYY

CLINICIAN: indicate where the child discloses engaging in sexual activity

1 In Home Country 1 During Journey to U.S. 1 In ORR Custody 1 In U.S. – not in ORR Custody

CLINICIAN: indicate which types of sexual activity the child has disclosed:

1 Oral 1 Vaginal 1 Anal 1 Other, Specify:

(Open Text)

If the child is sexually active, please ask the following: Have you ever had a sexual experience that you did not want to have?

1 Yes 1 No 1 Decline to Answer

If Yes, Explain:

(Open Text)

Have you ever felt like you needed to perform sexual actions or allow someone to touch, or take pictures and/or videos of your body in a sexual way in order to avoid harm, to get something you needed or wanted, or to be accepted by a person or group of people?

1 Yes 1 No

If Yes, Explain:

(Open Text)

Have you ever spoken to a counselor, social worker, psychologist, teacher, or any other adult because of a sexual experience you had – consensual or non-consensual?

1 Yes 1 No

If Yes, what was the outcome of this session? Did you find it helpful? Please Explain:

(Open Text)

If No, would the child like to speak with a counselor about this?

1 Yes 1 No

INSTRUCTIONS: After interviewing the child or youth and reviewing relevant case files and other records, Clinicians and Qualified Case Managers must use their professional opinion to answer the following questions:
QUESTIONS FOR CLINICIANS OR QUALIFIED CASE MANAGERS TO ANSWER
In your assessment, does the child or youth exhibit any heightened risk factors for sexual abuse or sexual victimization by others? For example, does the child exhibit any non-conforming appearance or mannerisms?	1 Yes 1 No
	If Yes, Explain:		(Open Text)
Does the child or youth have any current or past criminal charges?	1 Yes 1 No
	If Yes, Explain:		(Open Text)
Does the child or youth have any suspected or diagnosed mental, physical, or developmental disability or illness?	1 Diagnosed: 1 Mental 1 Physical 1 Developmental
	Explain		(Open Text)
	1 Suspected: 1 Mental 1 Physical 1 Developmental
	Explain:		(Open Text)
What is the child or youth’s physical size and stature?	1 Average 1 Smaller than Average 1 Larger than Average
Other Specific Information that may indicate heightened needs and/or additional safety precaution:	1 Yes 1 No
	If Yes, Explain:		(Open Text)
Does the child or caretaker in home country report any issues with the child’s ability to carry out any activities of daily living (e.g., showering, ambulating, toileting, eating, etc.) which may affect their housing assignment?	1 Yes 1 No
	If Yes, Explain:	(Open Text)

INSTRUCTIONS: After completing the above assessment, determine if any housing or other service assignments are needed to ensure the safety and well-being of the child or youth. Describe housing and other service assignments here. Indicate specific actions and follow-up. If housing and other service assignments are changed at any time, including after the initial placement, describe the change and the reason for the change.
HOUSING, OTHER SERVICE ASSIGNMENTS, AND FOLLOW-UP
Housing and Other Service Plan:	(Open Text)
In order to reduce the risk of sexual abuse or victimization by others, if the child or youth indicates any heightened risk factors as captured in the clinician assessment question above, describe the specific strategies and/ or interventions planned to keep the child safe.	Housing-related safety interventions are described below:
	(Open Text)
	Education and/ or activity group placement safety interventions are described below:
	(Open Text)
Actions Taken (Mark all that apply)	1 Clinician or Qualified Case Manager shared appropriate information with relevant care provider facility team.
	Explain:	(Open Text)
	1 Child or youth provided with psychoeducation
	Explain:	(Open Text)
	1 Child or youth provided with information on how to report threats, intimidation, or harassment by other children, youth, or facility staff.
	Explain:	(Open Text)
	1 Child has or will have an individual 504 Service Plan.
	Explain:	(Open Text)
	1 Developed and implemented an in-care safety plan between child or youth, clinician, and care provider staff
	Explain:	(Open Text)
	//DISPLAY FIELD: UPLOADED FILES//
	Attach in-care Safety Plan:		<File Upload field>					>| Upload
	1 Child or youth provided with additional or alternate restroom accommodations.
	Explain:			(Open Text)
	1 Implemented increased Clinical Sessions
	Explain:			(Open Text)
	1 Child or youth referred for professional/external mental health services
	Date of Referral			(Open Text) MM/DD/YYYY
	Explain:			(Open Text)
	1 Child or youth referred for medical services:
	Date of Referral			Date of Referral
	Explain:			Explain:
	1 Child or youth placed with closer staff supervision
	Explain:			(Open Text)
	1 Staffed with FFS and CC for possible transfer
	Explain:			(Open Text)
	1 Other
	Explain:			(Open Text)
	1 Other Attachments
	//DISPLAY FIELD: UPLOADED FILES//
	Attach File			<File Upload field>			>| Upload
	1 No specific action taken
	Explain:			(Open Text)

Document Display Tab
	Title	Record Type	Description	Date Received	Created by
1	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)
2	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)	(Auto-Populate)

Clinician Certification
Staff Signature:	(Open Text)	Date/ Time	SYSTEM GENERATED MM/DD/YYYY		SYSTEM GENERATED HH:MM AM/PM
Staff Name:	(Open Text)	1 I confirm that I have completed all the required sections and the information is accurate to the best of my knowledge.
Staff Title	(Open Text)
Translator’s Name:	(Open Text)	Last modified by:		SYSTEM GENERATED
Language	(Open Text)
>| Save >| Reset

APPENDIX

Reference Table 1: Language

<Dropdown Menu> ( - Select Language – Spanish; Acateco; K’iche’; Q’eqchi; Mam; Non-verbal; Sign Language; Unknown Dialect; Achi; Albanian; Arabic; Armenian; Asante; Awakatek; Azerbaijani; Bambara; Bengali; Cantonese Chinese; Chatino; Chechen; Chorti; Chuj; Creole – Haitian (French); Creole – Spanish; Czech; Dari; Dutch; Eman; English; Ewe; Fanti; Farsi (Persian); French; Fujianese; Fulani; Fuzhou; Ga; Garifuna; Georgian; German; Gujarati; Haryanvi; Hausa; Hebrew; Hindi; Hungarian; Italian; Ixil; Jacatelco (Popti); Japanese; Kaqchikel; Kikongo; Korean; Kotokoli; Kurdish; Kyrgyz; Lachi; Latvian; Lenka; Lingala; Malinke; Mandarin Chinese; Mandingo; Marwari; Maya; Mazatec; Miskito; Mixteco; Mopan; Nahuatl; Nepali; Otomi; Pashai; Pashto; Patois; Polish; Poqomam; Poqomchi; Portugese; Pular; Punjabi; Qanjobal; Quechua; Rohingya; Romani (Gypsy); Romanian; Russian; Serbian; Sipakapense; Slovak; Somali; Soinke; Susu; Swahili; Sylheti; Tajik; Tamil; Tarahumara; Tectiteco; Telugu; Thai; Thibetan; Tigrinya; Tlapanec; Tojolabal; Triqui; Turkish; Twi; Tzeltal; Tzotzil; Tz’utujil; Ukranian; Urdu; Uspanteko; Uzbek; Vietnamese; Wolof; Yoruba; Zaghawa; Zapotec; Zarma; Zoque)

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