Form S-11 UAC Assessment

OMB 0970-NEW; Valid Through MM/DD/YYYY

Administration for Children and Families

Office of Refugee Resettlement

Unaccompanied Alien Child Assessment (S-11)

UAC Portal Version with Integrated UAC Path Features

UAC PortalVersion with Integrated UAC Path Features

Child 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)

Additional Basic Child Information
City of Origin	(Open Text)	Neighborhood of Origin	(Open Text)
Previous Placement	(Open Text)
Religious Affiliation	(Open Text)
Case Manager	(Open Text)	Clinician	(Open Text)
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THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is for care providers to complete an in-depth assessment to document information about the UAC that is used to inform provision of services (e.g., case management, legal, education, medical, mental health, home studies), screen for trafficking or other safety concerns, and identify special needs Public reporting burden for this collection of information is estimated to average 2.25 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].

Journey and Apprehension
Describe day-to-day life in home country:				(Open Text)
What neighbors or other people were important in your daily life in COO?				(Open Text)
Why did you decide to travel to the U.S. at this time?				(Open Text)
Did someone you know come to the U.S. before you and tell you about opportunities in the U.S.?				(Open Text)
Did the child mention any U.S. immigration policy or practice as a factor in his or her decision to travel to the U.S.?				1 Yes 1 No
For children aged 14-17 ONLY: Did the child mention economic, job, or educational opportunities as a factor in his/her decision to travel to the U.S.?				1 Yes 1 No
When did you leave your home country (Month, Day, Year)?				(Open Text) MM/DD/YYYY
How did you get to the U.S.?				(Open Text)
Who did you travel with?				(Open Text)
Did you meet any adults along the journey with whom you built a trusting relationship?				1 Yes 1 No
If yes, what are their names?		(Open Text)		Where are they now?		(Open Text)
Who were you living with when you decided to leave your home country?				(Open Text)
Where were you planning on living in the U.S. and with whom?				(Open Text)
Who are some trusted adults the child knows at their intended destination?				(Open Text)
Where were you apprehended or at which Port of Entry did you arrive/ present yourself? At which U.S. Border Patrol sector did the child cross into the U.S.?				(Open Text)
Have you ever been to the U.S. before?				1 Yes 1 No
If yes, when?				(Open Text) MM/DD/YYYY
If yes, with whom did you live?				(Open Text)
The child’s experience and additional information regarding the journey and apprehension by/ encounter with CBP:				(Open Text)
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Family/ Significant Relationships

Name of parent or legal guardian:

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship)

First Name

(Open Text)

Last Name:

(Open Text)

Parent or Legal Guardian Address:

(Open Text)

1 Unknown

Parent/ Legal Guardian Phone:

(Open Text)

1 Unknown

Parent/ Legal Guardian Email:

(Open Text)

1 Unknown

Do you have family in country of origin? (If yes, list below)

1 Yes 1 No

Family in country of origin

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Name

Age

DOB

Relationship

Where do they live?

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship)

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship

(Open Text)

Has family in the U.S.? (If Yes, list below.

1 Yes 1 No

Family and family friends in the U.S.

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Name

Age

DOB

Relationship

Potential Sponsor?

Contact Information

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship)

1 Yes 1 No

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship)

1 Yes 1 No

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

<Dropdown Menu> (-Select Relationship- See Reference Table 1 – Relationship)

1 Yes 1 No

(Open Text)

Do you have family who previously lived in the U.S.?

1 Yes 1 No

Who?

(Open Text)

When?

(Open Text) MM/DD/YYYY

Do they still know people who live in the U.S.?

1 Yes 1 No

Parents’ whereabouts?

(Open Text)

Are you married?

1 Yes 1 No

Spouse name, age, and location:

(Open Text)

Children

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Name

Age

DOB

Current Location

Name of mother/ father

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

(Open Text)

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

(Open Text)

(Open Text)

(Open Text)

(Open Text)

(Open Text) MM/DD/YYYY

(Open Text)

(Open Text)

Have you ever been hurt physically, mentally, or emotionally by someone taking care of you?

1 Yes 1 No

If yes, who and when?

(Open Text)

Have you ever been taken to the hospital/ emergency room because you were hurt?

1 Yes 1 No

If yes, explain:

(Open Text)

What does the word “discipline” mean to you?

(Open Text)

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Medical
CLINICIAN: Does the child appear unwell or injured?				1 Yes 1 No
Specify:				(Open Text)
Does the child have any allergies to food, medication, or the environment?				1 Yes 1 No
Specify:				(Open Text)
Do you want to discuss any health concerns with a health care provider?				1 Yes 1 No
If yes, please specify:				(Open Text)
Does the child require any assistance with daily activities or mobility?				1 Yes 1 No
If yes, please specify:				(Open Text)
Does the child report any special dietary needs?				1 Yes 1 No
If yes, please specify:				(Open Text)
Additional medical information:				(Open Text)
Medical History
Condition			Yes/No			Date of Diagnosis/Certification
Pregnant			1 Yes 1 No			(Open Text)
Tuberculosis			1 Yes 1 No			(Open Text)
Varicella			1 Yes 1 No			(Open Text)
Measles			1 Yes 1 No			(Open Text)
Mumps			1 Yes 1 No			(Open Text)
Rubella			1 Yes 1 No			(Open Text)
Asthma			1 Yes 1 No			(Open Text)
Diabetes			1 Yes 1 No			(Open Text)
Cancer			1 Yes 1 No			(Open Text)
Cardiac Issues			1 Yes 1 No			(Open Text)
Sexually Transmitted Disease			1 Yes 1 No			(Open Text)
Respiratory/ Lung Disorder			1 Yes 1 No			(Open Text)
Physical Disability			1 Yes 1 No			(Open Text)
Medication History											>| Add New Row
Did the child arrive with any medications or report that they are supposed to take any medications?											1 Yes 1 No
If yes, please specify below:
Medication		Dosage		Timeframe/ Dosage Interval			Date/Time last taken		Medical Condition
(Open Text)		(Open Text)		(Open Text)			(Open Text) MM/DD/YYYY HH:MM AM/PM		(Open Text)
(Open Text)		(Open Text)		(Open Text)			(Open Text) MM/DD/YYYY HH:MM AM/PM		(Open Text)
(Open Text)		(Open Text)		(Open Text)			(Open Text) MM/DD/YYYY HH:MM AM/PM		(Open Text)
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Education
What is the highest level of education you have completed?		(Open Text)
When was the last time you were in school? What age?		(Open Text)
Have you ever been diagnosed with a learning disability (dyslexia, dysgraphia, auditory processing disorder etc.)?		1 Yes 1 No		If Yes, Specify:		(Open Text)
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Legal
Know your rights presentation provided?		1 Yes 1 No	When?		<Pop-up Calendar> (MM/DD/YYYY)
Confidential Legal Consultation Completed?		1 Yes 1 No	When?		<Pop-up Calendar> (MM/DD/YYYY)
Notice to appear filed?		1 Yes 1 No	When?		<Pop-up Calendar> (MM/DD/YYYY)
Scheduled for a hearing?		1 Yes 1 No	When?		<Pop-up Calendar> (MM/DD/YYYY)
			Where?		State	<Dropdown Menu> (-Select One- See Ref. Table 2: States)		City:		(Open Text)
			Outcome?		<Dropdown Menu> (-Select One- Continued; Granted Voluntary Departure; Ordered Removed; Administratively Closed; Granted Immigration Relief; Other)
Has Attorney?		1 Yes 1 No	Date of Meeting:		<Pop-up Calendar> (MM/DD/YYYY)
Any possible legal relief identified?		1 Yes 1 No	Specify:		(Open Text)
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Criminal History & Gang Affiliation
Any Criminal History? (If yes, list below)		1 Yes 1 No
List any felony convictions:		(Open Text)
List any misdemeanor convictions:		(Open Text)
List any probation/ parole:		(Open Text)
List and describe any disclosed criminal activity:		(Open Text)
Additional Information, including whether any criminal acts were the result of duress:		(Open Text)
Known Gang Affiliation?		1 Yes 1 No 1 Unknown 1 Suspect
Name of Gang:		(Open Text)
Gang Affiliation Summary:		(Open Text)
Determined by:		1 Self-admission of child 1 Gang Tattoos 1 Gang Affiliation Summary
History of Incarceration						>| Add New Row
	Crime		Date	Length of Sentence	Location
	(Open Text)		(Open Text) (MM/DDY/YYYY)	(Open Text)	(Open Text)
	(Open Text)		(Open Text) (MM/DDY/YYYY)	(Open Text)	(Open Text)
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Mental Health/ Behavior

Mental Status Evaluation

Attitude

1 Calm and Cooperative 1 Other

If other, describe:

(Open Text)

Behavior

1 No unusual movements or psycho-motor changes 1 Other

If other, describe:

(Open Text)

Speech

1 Normal Rate/ Tone/ Volume 1 Other

If other, describe:

(Open Text)

Affect

<Dropdown Menu> (-Select One- Reactive and mood congruent; Labile, Tearful; Blunted; Normal; Depressed; Constricted; Flat; Other)

If other, describe:

(Open Text)

Mood

<Dropdown Menu> (-Select One- Euthymic; Irritable; Elevated; Anxious; Depressed; Other )

If other, describe:

(Open Text)

Thought Process

1 Goal Oriented and Logical 1 Disorganized 1 Future Oriented 1 Other

If other, describe:

(Open Text)

Thought Content

Suicidal Ideation

Homicidal Ideation

1 None 1 Passive 1 Active

1 None 1 Passive 1 Active

If Active:

Plan

1 Yes 1 No

Plan

1 Yes 1 No

Intent

1 Yes 1 No

Intent

1 Yes 1 No

Means

1 Yes 1 No

Means

1 Yes 1 No

<Dropdown Menu> (-Please Select- Delusions; Obsessions; Phobias; Other)

If other, describe:

(Open Text)

Perception

1 No Hallucinations or delusions during interview 1 Other

Orientation

1 Time 1 Place 1 Person 1 Self 1 Other

If other, describe:

(Open Text)

Memory/ Concentration

1 Short term impact 1 Long term impact 1 Distractable/ Inattentive 1 Other

If other, describe:

(Open Text)

Insight/ Judgement

1 Good 1 Fair 1 Poor

Mental Health

Have you ever talked to a psychiatrist, therapist, social worker, or counselor about an emotional problem?

1 Yes 1 No

When?

(Open Text)

Have you ever felt you needed help with your emotional problems?

1 Yes 1 No

When?

(Open Text)

Have you had people tell you that you should get help for your emotional problems?

1 Yes 1 No

When?

(Open Text)

Have you ever been advised to take medication for anxiety, depression, hearing voices, or for any other emotional problems?

1 Yes 1 No

When?

(Open Text)

Have you ever been seen in an emergency room or been hospitalized for emotional problems?

1 Yes 1 No

When?

(Open Text)

Have you ever heard voices no one else could hear or seen objects or things that others could not see?

1 Yes 1 No

When?

(Open Text)

Have you ever been depressed for weeks at a time, lost interest, or pleasure in most activities, had trouble concentrating and making decisions, or thought about killing yourself?

1 Yes 1 No

When?

(Open Text)

Did you ever attempt to kill yourself?

1 Yes 1 No

When?

(Open Text)

Have you ever given in to an aggressive urge or impulse on more than one occasion that resulted in serious harm to others or led to the destruction of property?

1 Yes 1 No

When?

(Open Text)

Substance Use History

Substance

Used (even once)

Frequency of Use

Date of Last Use

Alcohol

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Marijuana

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Cocaine

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Other Stimulants (Meth, Ritalin, etc.)

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Heroin

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Other Opiates

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Nicotine

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

Inhalants (glue, paint thinner, gasoline, markers, cleaning fluids, etc.)

1 Yes 1 No

(Open Text)

(Open Text) MM/DD/YYYY

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Trafficking
Who planned your journey here?		(Open Text)
Did a family member or family friend pay for you to travel to the U.S.?		1 Yes 1 No
If yes, who?		(Open Text)
What were you told about the arrangements before the journey?		(Open Text)
Did the arrangements change during the journey?		1 Yes 1 No
Who did you meet along your journey?		(Open Text)
Do you have their contact information?		1 Yes 1 No
If yes, provide:		(Open Text)
If yes, how?		(Open Text)
Does your family or family friend owe money to anyone for the journey?		1 Yes 1 No
If yes, how much?		(Open Text) $########.##
To whom is the money owed?		(Open Text)
Who is expected to pay?		(Open Text)
What do you expect to happen if payment is not made?		(Open Text)
Coercion Indicators
Did anyone threaten you or your family?		1 Yes 1 No
If yes, who made the threats?		(Open Text)
Were you ever physically harmed?		1 Yes 1 No
If yes, how?		(Open Text)
Was anyone around you ever physically harmed?		1 Yes 1 No
If yes, who?		(Open Text)
Were you ever held against your will?		1 Yes 1 No
If yes, where?		(Open Text)
Did anything bad happen to anyone else in this situation or anyone else who tried to leave?		1 Yes 1 No
What happened and to whom?		(Open Text)
Did anyone ever keep/ destroy your documents?		1 Yes 1 No
If yes, who, and what?		(Open Text)
Did anyone ever threaten to report you to the police/ immigration?		1 Yes 1 No
If yes, who?		(Open Text)
Are you worries anyone might be trying to find you?		1 Yes 1 No
If yes, who?		(Open Text)
Debt Bondage/ Labor Trafficking
Did you perform any work or provide any services in exchange for help journeying to the United States or for reasons other than to meet your basic needs (e.g. food, housing, clothing)?		1 Yes 1 No
If yes, where?		(Open Text)
Who arranged the work?		(Open Text)
What type of work did you perform?		(Open Text)
What was the work schedule?		(Open Text)
Did work conditions change over time?		(Open Text)
Is there a debt?		1 Yes 1 No
If yes, has any debt amount increased?		1 Yes 1 No
By how much?		(Open Text)
When did it increase?		(Open Text)
Why did it increase?		(Open Text)
Have you or your family ever been threatened over payment or work for the journey?		1 Yes 1 No
If yes, who threatened you and how?		(Open Text)
What did you expect would happen if you left the job or stopped working?		(Open Text)
Were you ever made to work or do anything you did not want to do?		1 Yes 1 No
Did you receive pay or did someone else keep the pay?		(Open Text)
Were you paid what was promised when you started working?		(Open Text)
Were expenses taken out of the pay?		1 Yes 1 No
If yes, what?		(Open Text)
How did you get to the work site?		(Open Text)
Where did you live while working?		(Open Text)
Commercial Sex Indicators
Did anyone ever ask you to see you naked, or in your underwear in exchange for money/ anything of value?						1 Yes 1 No
Did anyone ever pay/ accept money/ anything of value from other people in order to see you naked or in your underwear?						1 Yes 1 No
Did anyone ever ask to take pictures or recording of you naked or engaged in sex acts?						1 Yes 1 No
If so, did they offer you money/ anything of value to do this, or did they accept money/ anything of value from other people in order to see these pictures or recordings?						1 Yes 1 No
Did anyone ever ask or expect you to perform sexual acts in exchange for money or anything of value?						1 Yes 1 No
Did anyone ever promise or give money or anything of value to you in exchange for sexual acts?						1 Yes 1 No
Based on information provided above in the “Trafficking section”, is there a trafficking concern?						1 Yes 1 No
If yes, date of trafficking referral:				(Open Text) MM/DD/YYYY
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Mandatory TVPRA 2008
Based on the most recent trafficking screening, is the child a victim of a severe form of trafficking in persons? (Indicate “yes” only if ORR has issued a trafficking eligibility letter for the child.)					1 Yes 1 No
Based on the most recent screening for disabilities, does the child have a disability as defined in section 3 of the Americans with Disabilities Act of 1990, 42 U.S.C. § 12102(1) which defines a person with a disability as someone with a physical or mental impairment that substantially limits one or more major life activities or has a history of such an impairment.?					1 Yes 1 No
If yes, specify disability or concerns requiring further evaluation:		(Open Text)
Based on the most recent screening, has the child been a victim of physical or sexual abuse under circumstances that indicate that the child’s health or welfare has been significantly harmed or threatened?					1 Yes 1 No
If yes, provide a short summary:		(Open Text)
Based on the sponsor risk assessment, does the sponsor clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the child?					1 Yes 1 No
If yes, provide a short summary:		(Open Text)
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Additional Information
Please input any additional information if needed:			(Open Text)
Link to Journey Mapping			<File Upload Address> (Source: UC Documents)			L >|Search
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Certification
Signature:	(Open Text)	Date:		(Open Text) MM/DD/YYYY
		Printed Name:		(Open Text)
		Title:		(Open Text)
Was an interpreter or translation service used in the performance of this assessment?			1 Yes 1 No
If yes, Specify:
Interpreter Name:	(Open Text)	Interpreter language:		<Dropdown Menu> (-Select One- See Ref. Table 3: Languages)
Interpreter Signature	(Open Text)	Date:		(Open Text) MM/DD/YYYY
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APPENDIX

Reference Table 1 – General Relationship to Child

<Dropdown Menu> ( -Select Relationship – Adult First Cousin; Adult Nephew; Adult Niece; Aunt; Brother; Brother-in-law; Daughter; Daughter-in-Law; Family Friend; Father; First Cousin; Goddaughter; Godfather; Godmother; Godson; Granddaughter; Grandfather; Grandmother; Grandson; Half-sibling; Institutional/ Organizational Sponsor; Legal Guardian; Mother; Nephew; Niece; Other Cousin; Other Distant Relative; Parent’s Partner; Qualified Step Parents; Sister; Sister-in-Law; Son; Son-in-law; Sponsor’s Partner; Stepdaughter; Stepbrother; Stepfather; Stepmother; Stepson; Stepsister; Child’s Spouse; Uncle; Unknown; Unrelated Sponsor)

Reference Table 2 – U.S. States and Territories

<Dropdown Menu> (-Select State- Alabama; Alaska; Arizona; Arkansas; American Samoa; California; Colorado; Connecticut; Delaware; District of Columbia; Florida; Georgia; Guam; Hawaii; Idaho; Illinois; Indiana; Iowa; Kansas; Kentucky; Louisiana; Maine; Maryland; Massachusetts; Michigan; Minnesota; Mississippi; Missouri; Montana; Nebraska; Nevada; New Hampshire; New Jersey; New Mexico; New York; North Carolina; North Dakota; Northern Mariana Islands; Ohio; Oklahoma; Oregon; Pennsylvania; Puerto Rico; Rhode Island; South Carolina; South Dakota; Tennessee; Texas; Trust Territories; Utah; Vermont; Virginia; U.S. Virgin Islands; Washington; West Virginia; Wisconsin; Wyoming)

Reference Table 3 - Languages

<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)

S-11 | Version #.#

MM/DD/YYYY

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