Form S-12 UAC Case Review

OMB 0970-NEW Valid Through MM/DD/YYYY

Administration for Children and Families

Office of Refugee Resettlement

Unaccompanied Alien Child Case Review (S-12)

UAC Portal Version with Integrated UAC 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)

1 30-Day Case Review 1 Discharge 1 Transfer

Are there any changes?

1 Yes 1 No

Previous Placement	(Auto Populate)
Religious Affiliation	(Auto Populate)
Case Manager	(Auto Populate)	Clinician	(Auto Populate)
Document any new information regarding the child not indicated in the UAC Assessment and/or the previous case summary below.

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow care providers to document new information obtained after completion of the UAC Assessment. Public reporting burden for this collection of information is estimated to average 0.5 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].

Medical
Does the child have any health concerns (medical, mental health, dental) that have not been evaluated by a healthcare provider? If yes, specify:	1 Yes 1 No	(Open Text)
Does the child have any health-related travel restrictions? If yes, specify:	1 Yes 1 No	(Open Text)
Provide a short summary of the child's medical and/or psychological functioning:	(Open Text)
If the child is ready for discharge, does the child have any health problems, including dental and mental health, that require follow-up after release from ORR care? If yes, Specify:	1 Yes 1 No	(Open Text)
List all scheduled or pending health appointments or interventions:	(Open Text)
Describe follow-up care plan:	(Open Text)

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)
Any possible legal relief identified?	1 Yes 1 No	Specify:	(Open Text)
What is the child’s legal care plan?	(Open Text)

Criminal History & Gang Affiliation
New 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 by Child 1 Gang Tattoos 1 Gang Affiliation Summary

Trafficking
Who planned/ organized your journey here?	(Auto-Populate) Source: UAC Assessment
What were you told about the arrangements before the journey?	(Auto-Populate) Source: UAC Assessment
Did the arrangements change during the journey?	(Auto-Populate) Source: UAC Assessment
Who did you meet along your journey?	(Auto-Populate) Source: UAC Assessment
Do you have their contact information?	(Auto-Populate) Source: UAC Assessment
If yes, provide:	(Auto-Populate) Source: UAC Assessment
If yes, how?	(Auto-Populate) Source: UAC Assessment
Does your family or family friend owe money to anyone for the journey?	(Auto-Populate) Source: UAC Assessment
If yes, how much?	(Auto-Populate) Source: UAC Assessment
To whom is the money owed?	(Auto-Populate) Source: UAC Assessment
Who is expected to pay?	(Auto-Populate) Source: UAC Assessment
What do you expect to happen if payment is not made?	(Auto-Populate) Source: UAC Assessment
Coercion Indicators
Did anyone threaten you or your family?	1 Yes 1 No
If yes, who made the threats?	(Auto-Populate) Source: UAC Assessment
Were you ever physically harmed?	(Auto-Populate) Source: UAC Assessment
If yes, how?	(Auto-Populate) Source: UAC Assessment
Was anyone around you ever physically harmed?	(Auto-Populate) Source: UAC Assessment
If yes, who?	(Auto-Populate) Source: UAC Assessment
Were you ever held against your will?	(Auto-Populate) Source: UAC Assessment
If yes, where?	(Auto-Populate) Source: UAC Assessment
Did anything bad happen to anyone else in this situation or anyone else who tried to leave?	(Auto-Populate) Source: UAC Assessment
What happened and to whom?	(Auto-Populate) Source: UAC Assessment
Did anyone ever keep/ destroy your documents?	(Auto-Populate) Source: UAC Assessment
If yes, who, and what?	(Auto-Populate) Source: UAC Assessment
Did anyone ever threaten to report you to the police/ immigration?	(Auto-Populate) Source: UAC Assessment
If yes, who?	(Auto-Populate) Source: UAC Assessment
Are you worries anyone might be trying to find you?	(Auto-Populate) Source: UAC Assessment
If yes, who?	(Auto-Populate) Source: UAC Assessment
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)?	(Auto-Populate) Source: UAC Assessment
If yes, where?	(Auto-Populate) Source: UAC Assessment
Who arranged the work?	(Auto-Populate) Source: UAC Assessment
What type of work did you perform?	(Auto-Populate) Source: UAC Assessment
What was the work schedule?	(Auto-Populate) Source: UAC Assessment
Did work conditions change over time?	(Auto-Populate) Source: UAC Assessment
Is there a debt?	(Auto-Populate) Source: UAC Assessment
If yes, has any debt amount increased?	(Auto-Populate) Source: UAC Assessment
By how much?	(Auto-Populate) Source: UAC Assessment
When did it increase?	(Auto-Populate) Source: UAC Assessment
Why did it increase?	(Auto-Populate) Source: UAC Assessment
Have you or your family ever been threatened over payment or work for the journey?	(Auto-Populate) Source: UAC Assessment
If yes, who threatened you and how?	(Auto-Populate) Source: UAC Assessment
What did you expect would happen if you left the job or stopped working?	(Auto-Populate) Source: UAC Assessment
Were you ever made to work or do anything you did not want to do?	(Auto-Populate) Source: UAC Assessment
Did you receive pay or did someone else keep the pay?	(Auto-Populate) Source: UAC Assessment
Were you paid what was promised when you started working?	(Auto-Populate) Source: UAC Assessment
Were expenses taken out of the pay?	(Auto-Populate) Source: UAC Assessment
If yes, what?	(Auto-Populate) Source: UAC Assessment
How did you get to the work site?	(Auto-Populate) Source: UAC Assessment
Where did you live while working?	(Auto-Populate) Source: UAC Assessment
Commercial Sex Indicators
Did anyone ever ask you to see you naked, or in your underwear in exchange for money/ anything of value?			(Auto-Populate) Source: UAC Assessment
Did anyone ever pay/ accept money/ anything of value from other people in order to see you naked or in your underwear?			(Auto-Populate) Source: UAC Assessment
Did anyone ever ask to take pictures or recording of you naked or engaged in sex acts?			(Auto-Populate) Source: UAC Assessment
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?			(Auto-Populate) Source: UAC Assessment
Did anyone ever ask or expect you to perform sexual acts in exchange for money or anything of value?			(Auto-Populate) Source: UAC Assessment
Did anyone ever promise or give money or anything of value to you in exchange for sexual acts?			(Auto-Populate) Source: UAC Assessment
Based on information provided above in the “Trafficking section”, is there a trafficking concern?			(Auto-Populate) Source: UAC Assessment
If yes, date of trafficking referral:		(Auto-Populate) Source: UAC Assessment

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:	(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)

Recommendations
Discharge:		1 Yes 1 No	Sponsor:	(Auto Populate)
Discharge with Post-Release:		1 Yes 1 No	Date of PR Referral:	<Pop-up Calendar> (MM/DD/YYYY)
What level PRS is recommended for this child and sponsor?		1 Level 1 1 Level 2 1 Level 3
Refer to Home Study:		1 Yes 1 No	Reason for HS Referral:	(Open Text)
Home Study		1 TVPRA Mandated 1 ORR Mandated 1 ORR Discretionary
Concurrent Planning
This case is undergoing concurrent planning			1 Yes 1 No
Alternative Potential Sponsors
	First Name	Last Name	Email	Phone	Sponsor Category	Current Status
1	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment
2	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment	(Auto-Populate) Source: Sponsor Assessment

Care Plan
Reunification
Unification Specialist Comments:		(Open Text)
See Mental Health
Clinician Comments	(Open Text)
General Child Behavior & Wellbeing
Case Manager Comments:	(Open Text)

Certification
Signature:	(Open Text)		Date:		(Open Text) MM/DD/YYYY
			Print Name:		(Open Text)
			Title:		(Open Text)
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S-12 | Version #.#

MM/DD/YYYY