Form S-13 Individual Service Plan

OMB 0970-XXXX Valid Through MM/DD/YYYY

Administration for Children and Families

Office of Refugee Resettlement

Individual Service Plan (S-13)

UAC Portal Version with Integrated UC Path Features

DATA ENTRY WINDOW: UC Path New Admission Assessment – Individual Service Plan

Information
Assessment Status	<Dropdown Menu> (-Select One- Pending; Complete)
System Information
Submitted Date	<Pop-up Calendar> MM/DD/YYYY
	>|Cancel	>|Save & New		>|Save

DATA ENTRY WINDOW: UC Path Mandatory Services

New Service: Mandatory
Service*	<Dropdown Menu> (-Select One- Orientation, Assessment, Medical, Education; Recreation & Leisure Time; Individual Counseling; Group Counseling; Access to Religious Services; Case Management; Legal Orientation; Vocation)
Task*	<Dropdown Menu> (*Conditional Logic* See Ref. Table 3: ISP Task)
Person Responsible*	(Open Text)	Notes:	(Open Text)
Dates
Service Start Date*	<Pop-up Calendar> MM/DD/YYYY	Service End Date	<Pop-up Calendar> MM/DD/YYYY
Frequency*	(Open Text)
	>|Cancel	>|Save & New	>|Save

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is used by care providers to document all services provided to the child. 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].

DATA ENTRY WINDOW: UC Path Other Services

New Service: Optional
Service*	<Dropdown Menu> (-Select One- Orientation, Assessment, Medical, Education; Recreation & Leisure Time; Individual Counseling; Group Counseling; Access to Religious Services; Case Management; Legal Orientation; Vocation; None)
Task*	<Dropdown Menu> (*Conditional Logic* See Ref. Table 3: ISP Task)	Notes:	(Open Text)
Person Responsible*	(Open Text)
Dates
Service Start Date*	<Pop-up Calendar> MM/DD/YYYY	Service End Date	<Pop-up Calendar> MM/DD/YYYY
Frequency*	(Open Text)
	>|Cancel	>|Save & New	>|Save

DATA ENTRY WINDOW: Documents Upload Tab

Add File Details
Record Type:	<Dropdown Menu> (-Select One- See Records Type List)
Title	(Open Text)
Document Type	<Dropdown Menu> (-Select One- See Ref Table 1: Document Type List)
Date Document Issued (if Applicable)	<Pop-up Calendar> MM/DD/YYYY
Date Received:	<Pop-up Calendar> MM/DD/YYYY
Expiration Date (if applicable):	<Pop-up Calendar> MM/DD/YYYY	Description:		(Open Text)
			>|Save

DATA ENTRY WINDOW: ISP Certification Tab

Certification (Case Manager)
List Team Individuals who Contributed to ISP:*	(Open Text)
1 I confirm that I have completed all of the required sections and the information is accurate to the best of my knowledge
Printed Name:*	<Search Field> (Help Text: Search undefined…)	Title		(Auto-Populate)
Translator Name: *	(Open Text)	Language: *		<Dropdown Menu> (-Select Language- See Ref. Table 2: Languages)
			>|Save
System Information
Created by:	SYSTEM GENERATED	Last Modified by:		SYSTEM GENERATED
		Submitted Date/Time:		SYSTEM GENERATED

DISPLAY: UAC Portal ISP with Integrated UC Path Features – REDLINE CHANGES

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)

Individual Service Plan
Case Manager	(Auto Populate)	Clinician	(Auto-Populate)
Assessment Status:	(Auto-Populate)
Does the child have a 504 Service Plan?	(Auto-Populate)
System Information
Submitted Date	(Auto-Populate) MM/DD/YYYY

Service	Task	Frequency	Start Date	End Date	Person Responsible
Orientation	Program Orientation	One Time	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Assessment	UAC Assessment	One Time	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Medical	Medical Exam w/in 48 Hours of Admission	One Time	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Education	Assessment	One Time	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
	Plan	One Time	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
	Classes	Daily	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Recreation and Leisure	Large Muscle Activity and Leisure Time	1 hour of each/ weekday; 5 hours total/ weekends	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Individual Counseling	Session	Once Weekly	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Group Counseling	Session	Twice Weekly (or once weekly with community meeting)	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Access to Religious Services	Attendance	Upon Request	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Case Management	Discharge Planning; Family Reunification	Ongoing Once Weekly Meetings with UAC for updates	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Legal Orientation	KYR Presentation; Confidential Legal Consultation	One time each	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)
Vocation	Training Activities	Once Weekly	(Auto-Populate) MM/DD/YYYY	(Auto-Populate) MM/DD/YYYY	(Auto-Populate)

Other Services
Service	Tasks	Frequency	Start Date	End Date	Person Responsible
Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate
Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate
Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate	Auto-Populate

Certification (Case Manager)
List Team Individuals Who Contributed to ISP:*	Auto-Populate
1 I confirm that I have completed all of the required sections and the information is accurate to the best of my knowledge
Printed Name:*	(Auto-Populate)	Title		(Auto-Populate)
Translator Name:*	(Auto-Populate)	Language:*		(Auto-Populate)
System Information
Created by:	SYSTEM GENERATED	Last Modified by:		SYSTEM GENERATED
		Submitted Date/ Time:		SYSTEM GENERATED
Certificate
Signature:	(Auto-Populate)	Date:	(Auto-Populate)
Print Name:	(Auto-Populate)	Title:	(Auto-Populate)

APPENDIX: A – UC Path User Interface

The images below depict the user interface design for Individual Service Plan data entry and display as contemplated for UC Path, currently approved under the Services Provided to Unaccompanied Alien Children information Collection (OMB# 0970-0553)

DATA ENTRY:

DISPLAY:

Sex

APPENDIX B: Reference Tables

Reference Table 1: Document Type

<Dropdown Menu> (-Select Document Type- UAC Identity Document; Sponsor’s Authorization for Release of Information; Sponsor’s Family Reunification Application; Sponsor’s Supporting Documents; Household Member Documents; Adult Caregiver Documents; Proof of Sponsor-UAC Relationship; Proof of Address; Cancelled Sponsor Application Documents; Case Management Notes; Clinical Notes; Home Study Report; PRS Report; UAC DHS/ Legal Documents; L-3 Form; Notification of Concern; 504 Service Plan (S-25); Other)

Reference Table 2: 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)

Reference Table 3: ISP Task Options Conditional Logic
If this “Service” is selected in the New Services (Mandatory or Optional) data entry window…	…Then these options auto-populate the “Task” field in the New Contract data entry window
Orientation	Program Orientation
Assessment	UAC Assessment
Medical	Medical Exam w/in 48 Hours of Admission; Other - Specify
Education	Assessment; Plan; Classes; Other - Specify
Recreation and Leisure	Large Muscle Activity and Leisure Time; Other - Specify
Individual Counseling	Session; Other - Specify
Group Counseling	Session; Other - Specify
Access to Religious Services	Attendance; Other - Specify
Case Management	Discharge Planning; Family Reunification; Other - Specify
Legal Orientation	KYR Presentation; Confidential Legal Consultation; Other - Specify
Vocation	Training Activities; Other - Specify

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