Form A-6 Home Study Assessment

OMB 0970-NEW [valid through MM/DD/YYYY]

Administration for Children & Families

Office of Refugee Resettlement

Home Study Assessment

Unaccompanied Alien Child Basic Information

Child Name AUTOPOPULATE A# [no spaces] AUTOPOPULATE

Also Known As AUTOPOPULATE Date of Birth AUTOPOPULATE

Age AUTOPOPULATE Country of Birth AUTOPOPULATE

Admission Date AUTOPOPULATE Sex

Sponsor Identifying Information

Sponsor AUTOPOPULATE Address AUTOPOPULATE

Date of Birth AUTOPOPULATE City AUTOPOPULATE

Sex State AUTOPOPULATE

Country of Birth AUTOPOPULATE Zip Code AUTOPOPULATE

Marital Status AUTOPOPULATE Phone Number AUTOPOPULATE

Sponsor Category AUTOPOPULATE Relationship to Child

Case Information

Date Referred for Home Study AUTOPOPULATE

Date of Home Visit <Pop-up Calendar> MM/DD/YYYY

Assessment Completion Date <Pop-up Calendar> MM/DD/YYYY

CURRENT CARE PROVIDER CONTACT INFORMATION

Current Care Provider Facility Name AUTOPOPULATE

Care Provider Staff Name AUTOPOPULATE

Care Provider Staff Phone AUTOPOPULATE

Care Provider Staff Email AUTOPOPULATE

ASSIGNED PROVIDER AGENCY CONTACT INFORMATION

Assigned Provider Agency AUTOPOPULATE

Assigned Supervisor Name AUTOPOPULATE Assigned Caseworker Name AUTOPOPULATE

Supervisor Phone AUTOPOPULATE Caseworker Phone AUTOPOPULATE

Supervisor Email AUTOPOPULATE Caseworker Email AUTOPOPULATE

ASSIGNED SUBCONTRACTOR CONTACT INFORMATION

Only complete if applicable.

Assigned Subcontractor AUTOPOPULATE

Subcontractor Provider Name AUTOPOPULATE

Subcontractor Phone AUTOPOPULATE

Subcontractor Email AUTOPOPULATE

Reason for Referral

Referral Type

Reason for Referral:

• Child’s potential sponsor clearly presents a risk of abuse, maltreatment, exploitation, or trafficking to the child based on all available objective evidence

• Child is a victim of a severe form of human trafficking in persons

• Child has 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

• Child has a disability as defined by the Americans with Disabilities Act of 1990, as amended (42 U.S.C. 12102) and requires particular services or treatment

• Child is aged 12 or under and unrelated to the potential sponsor

• Potential sponsor is seeking to concurrently sponsor two (2) or more children (regardless of whether the potential sponsor has previously sponsored or sought to sponsor a child) and at least one (1) of the children is unrelated to the potential sponsor

• Potential sponsor has previously been the sponsor of two (2) or more children and is now seeking to sponsor one (1) or more additional children (regardless of whether the previous or current children are related to the potential sponsor)

• Other concerns where a home study may provide additional information to determine that the sponsor is able to care for the health, safety and well-being of the child

Additional Information Supporting Referral (if necessary)

(OPEN TEXT)

Household Members

SYSTEM GENERATED (##)

Household Members

Contact Name (OPEN TEXT) + -
Date of Birth	Age	Sex	Dependent upon sponsor income?
(OPEN TEXT)	SYSTEM GENERATED	<Dropdown Menu> (-Select One- Male; Female)	<Dropdown Menu> (-Select One- Yes; No)
Relationship to Child	Relationship to Sponsor	Type of Bed	Bedroom Number
<Dropdown Menu> (See: Ref. Table 2)	<Dropdown Menu> (See: Ref. Table 2)	(OPEN TEXT)	(OPEN TEXT)
Present During Home Study?	Child Abuse/Neglect (CA/N) Check?	Sex Offender Registry Check?	Fingerprinted?
<Dropdown Menu> (-Select One- Yes; No)	<Dropdown Menu> (-Select One- Yes; No)	<Dropdown Menu> (-Select One- Yes; No)	<Dropdown Menu> (-Select One- Yes; No)

Community Resources

SYSTEM GENERATED (##)

Community Resources

Contact Name (OPEN TEXT) + -
Type	Address	City	State	Zip	Phone Number
<Dropdown Menu> (-Select One- School; Mental Health; Community Resource)	(OPEN TEXT)	(OPEN TEXT)	(OPEN TEXT)	(OPEN TEXT)	(OPEN TEXT)
Comments
(OPEN TEXT)

Unaccompanied Child Background

Describe the child's background.

For example, their upbringing, family in their home country, their past and current relationships (if known), reasons for migration, their primary language or dialect, education, prior experience in ORR custody.

(OPEN TEXT)

Does the child have a pre-existing relationship with their sponsor? _{Yes No} Describe the pre-existing relationship of the child and sponsor.

(OPEN TEXT)

_{Were Significant Incident Reports (SIRs) created for the} child while in ORR care? _{Yes No}

Provide a brief summary of the SIRs that are relevant to the home study.

(OPEN TEXT)

Does the child know if there are other individuals living in the sponsor's home? _{Yes No} Describe the child’s relationship with the other household members.

(OPEN TEXT)

_{Does the child} have any physical disabilities (e.g., limited mobility, visual impairment, hearing loss, etc.)? _{Yes No}

If yes, please describe.

(OPEN TEXT)

Does the child have any developmental disabilities, developmental delays, or learning problems? _{Yes No}

If yes, please describe.

(OPEN TEXT)

Does the child have any serious health conditions, including mental health conditions? _{Yes No}

If yes, please describe.

(OPEN TEXT)

Is the child currently taking any prescribed medication? _{Yes No}

If yes, please list all routine medication the child is taking.

(OPEN TEXT)

Does the child have any special dietary needs? _{Yes No}

If yes, please list below.

(OPEN TEXT)

Does the child routinely use any medical equipment (e.g., wheel chair, hearing aids, mobility aids, prosthetics devices, etc.)?

_{Yes No}

If yes, please list below.

(OPEN TEXT)

Does the child have an individualized Section 504 Plan? _{Yes No}

If yes, summarize the services or accommodations recommended in the child’s 504 plan that will need to be maintained post-release:

(OPEN TEXT)

Does the child have any specific concerns about living with the sponsor? _{Yes No} If yes, describe the child's concerns about living with the sponsor.

(OPEN TEXT)

What does the child see as the benefit of being released to this sponsor?

(OPEN TEXT)

Does the child have other family members in the United States who can potentially provide additional support? Yes No

If yes, describe the child’s family members in the United States who can potentially provide additional support.

(OPEN TEXT)

What are the child's expectation of reunification with the sponsor (including home environment, lifestyle, chores, religion, and education)?

(OPEN TEXT)

Does the child require additional support or strength-based services after release from ORR custody for any of the following?

Yes No

If yes, check all that apply.

• Criminal Charges

• Substance Use

• Gang Involvement or Affiliation

If Yes, describe:

(OPEN TEXT)

How does the child plan to address these behaviors?

(OPEN TEXT)

Are there any services that the child feels would be helpful after release? _{Yes No}

If yes, describe the services that would be helpful for the child to receive after release.

(OPEN TEXT)

Describe any previous unaccompanied alien child sponsorships in detail.

(OPEN TEXT)

Additional background information.

(OPEN TEXT)

Sponsor Background Information

_{Does the sponsor have any major medical} concerns? _{Yes No}

If yes, describe the sponsor's medical issues, and treatment and care plan.

(OPEN TEXT)

_{Does the sponsor have any mental health} concerns? _{Yes No}

If yes, describe the sponsor's mental health issues.

(OPEN TEXT)

_{Does the sponsor have a disability? Yes No}

If yes, describe what reasonable accommodations, if any, are required to facilitate the child’s safe release to the sponsor.

(OPEN TEXT)

_{Does the sponsor have any} prior or current substance use concerns/issues? _{Yes No}

If yes, describe the sponsor's substance use issues, and treatment and care plan.

(OPEN TEXT)

What are the sponsor's coping mechanisms as it pertains to the concerns reported above?

(OPEN TEXT)

How does the sponsor manage the concerns reported above?

(OPEN TEXT)

Identify and describe the sponsor's significant relationships and other support systems.

(OPEN TEXT)

Describe the sponsor's background.

For example, the sponsor's age, background, interests, strengths, weaknesses, etc.

(OPEN TEXT)

Ask the sponsor to list any local resources they rely on or consider to be an asset to the community (ex: libraries, parks, clinics, church, community center, nonprofit organizations, social/ affinity groups, etc. ):

(OPEN TEXT)

Follow up: Does the sponsor appear to be knowledgeable/ familiar with their community? _{Yes No}

What is the sponsor's English proficiency?

(OPEN TEXT)

What is the sponsor's proficiency in the child's native language?

(OPEN TEXT)

Information Provided to the Sponsor (check all that apply)

• The sponsor was provided information in U.S. laws in regard to employment.

• The sponsor was informed about age and document requirements for work, work permits, and employee rights.

• The sponsor was provided with information on the four types of abuse (sexual, physical, emotional, and neglect).

• The sponsor was also informed about the confidentiality of reporting child abuse and the different locations where it could be reported (e.g., police station, school, fire department, medical clinic), in addition to mandated reporters (therapist, social worker, counselor, and teacher).

• The sponsor was provided with information on school enrollment, sponsor's rights to contact the school, and student's rights to seek services.

• For a child with an identified disability: The sponsor was provided information regarding the child’s disability-related needs and specific post-release services and supports available in the sponsor’s community.

In the sponsor's own words, describe their understanding of the above.

(OPEN TEXT)

Sponsor's Motivation and Relationship to Child

Describe the sponsor's reasons for wanting to sponsor and care for the child.

(OPEN TEXT)

Describe the sponsor's relationship with the child and the child's family members.

For example, the frequency and quality of contact, the last face-to-face and phone contact between the sponsor and child.

(OPEN TEXT)

Does the sponsor have a family support system in the U.S.? ^{Yes No}

If yes, describe.

(OPEN TEXT)

^{Is the sponsor's family support system in the immediate area to provide assistance?} Yes ^No

Was the sponsor aware or involved in the child's plan to migrate to the U.S.? ^{Yes No}

If yes, describe.

(OPEN TEXT)

Describe the sponsor's awareness of any financial obligation for the child's travel to the U.S.?

(OPEN TEXT)

Was the sponsor aware of the child's apprehension by border authorities? ^{Yes No}

Is the sponsor aware of whether the child experienced any challenges or trauma on their journey or along the way?

Yes ^No

If yes, describe the challenges or trauma the UAC experienced on their journey or along the way.

(OPEN TEXT)

Sponsor's Parenting Ability

Describe the sponsor's parenting skills and abilities, their nature, and extent of previous experience with child supervision.

For example, discipline, parenting style, and designation of household responsibilities and chores.

(OPEN TEXT)

Is the sponsor aware of state and local laws on supervision of children? ^{Yes No}

What is the sponsor's supervision plan? If the sponsor is not available to supervise the child, who will provide supervision during the sponsor's absence?

(OPEN TEXT)

Are there any other children in the home? ^{Yes No}

If yes, describe whether the needs of the other children in the home are being met.

(OPEN TEXT)

What are the sponsor's discipline methods? Is physical discipline used?

(OPEN TEXT)

Are any significant life changes planned in the sponsor's future which would affect the sponsor's ability to care for the child (i.e., change in residence, marriage, divorce)? Yes ^No

^{Will these life changes affect the sponsor's ability to care for the child?} Yes ^{No N/A}

If yes, describe life changes and plans to accommodate the child?

(OPEN TEXT)

^{Is the sponsor aware of the UAC's current behavior issues (if any), criminal history, and/or significant trauma?}

Yes ^{No N/A}

How will the sponsor be able to provide support to the child in light of these behavior issues, criminal history, and/or significant trauma?

(OPEN TEXT)

What is the sponsor’s understanding of the child’s health needs?

(OPEN TEXT)

What is the sponsor’s understanding of the child’s mental health needs?

(OPEN TEXT)

Is the sponsor prepared to support the health needs of the child? ^{Yes No}

How will the sponsor provide support to these needs?

(OPEN TEXT)

^{Does the sponsor foresee any challenges in parenting the child?} Yes ^No How will the sponsor assess these challenges in parenting?

(OPEN TEXT)

Does the sponsor understand the dynamics of separation, grief, and loss as it relates to child development?

Yes ^No

Legal Services

How will the sponsor help the child cope with emotions of separation, grief, and loss?

(OPEN TEXT)

Did the sponsor attend a Legal Orientation Program for Custodians presentation? Yes No

What is the sponsor's plan to ensure the child's attendance at all immigration court proceedings and comply with DHS requirements?

(OPEN TEXT)

How will the sponsor secure legal representation for the child?

(OPEN TEXT)

Is there an immigration attorney representing the child? Yes No

Name of Attorney (OPEN TEXT) Attorney Phone Number (OPEN TEXT)

Attorney Address (OPEN TEXT)

Financial

Sponsor Employment Status (OPEN TEXT)

Name of Employer (OPEN TEXT) Type of Employer (OPEN TEXT)

Monthly Income (OPEN TEXT) Total Annual Income of Sponsor (OPEN TEXT)

Length of time employed at current job (if applicable) (OPEN TEXT)

Other Sources of Income

(OPEN TEXT)

Hours Worked Per Week

(OPEN TEXT)

Does the applicant operate a business from the residence? Yes No Is the business a children's daycare? Yes No

Is the business an adult daycare or rooming house? ^{Yes No}

Describe the type of business the sponsor operates.

(OPEN TEXT)

Describe the impact of the home business on the plan of the sponsor to care for the child.

(OPEN TEXT)

Sponsor Expenses

(OPEN TEXT)

How does the sponsor plan to financially support the child?

(OPEN TEXT)

Does the sponsor understand that they are not authorized to charge the child or their family any fees or be reimbursed for their costs? ^{Yes No}

Home and Community

Type of Sponsor Housing

Other Type of Housing (OPEN TEXT)

Which of the following accessible features are present in the sponsor home?

Check all that apply

• Exterior ramps

• Elevator

• Grab bars

• Wide hallways and doorways

• Motion-sensitive lighting

• Walk or Roll-In Shower/Tub

• Low counters

• Raised-height toilet

• Other

If other, please describe.

(OPEN TEXT)

^{Does the sponsor own or rent their housing? Own Rent}

Has the landlord approved the UAC living in the residence?

Note the reason for not informing or receiving approval from the landlord and the sponsor's plan to confirm approval.

(OPEN TEXT)

^{Are sleeping quarters and common areas handicapped accessible? Yes No}

How long has the sponsor resided at this residence? Do any household members smoke? ^{Yes No Is smoking allowed in the house?} Yes No

Is there a functional smoke detector?

Are there weapons in the home?

Yes No

Yes No

Are the weapons and ammunition kept separately in locked areas? Yes No

^{Are there pets in the home?} Yes No List pets in home.

(OPEN TEXT)

Do pets meet local safety requirements (vaccinations, vicious animal restrictions, etc.)? Yes No

Outside Space

Patio	Play Equipment	Attached Garage
Hot Tub	Porch	Pool/Pond/Lake
Fenced Yard	Deck	Fenced and Locked Gate
Detached Garage	Shed/Barn	Handicapped Accessible
Other (conditional)

Other Outside Space (specify)

(OPEN TEXT)

Describe how sponsor will ensure safety and supervision of UAC around the pool, pond, or lake.

(OPEN TEXT)

Is there evidence that individuals other than those listed in the Family Reunification Packet are living in the home?

Yes No

If yes, explain:

(OPEN TEXT)

^{Are there safety concerns or health hazards in the home or outside space?} Yes No How can safety concerns or health hazards be resolved?

(OPEN TEXT)

Does the sponsor have a means of transportation? Yes No

Describe the sponsor's means of transportation.

(OPEN TEXT)

Are vehicles insured? Yes No

Does the sponsor know how to access public transportation? Yes No

Is the home accessible by public transportation? Yes No

Briefly describe the community in which the home is located.

Include information regarding the type of neighborhood (rural, urban, residential, industrial, etc.).

(OPEN TEXT)

Does the sponsor know who to call in case of an emergency? Yes No Describe the sponsor's emergency contact(s).

(OPEN TEXT)

Summary

Based on all of the information collected during the home study process, provide an assessment of the sponsor's ability to provide and maintain a safe, stable, and appropriate home environment. Elaborate on the sponsor's parenting experience, supervision, and ability to ensure the safety and well-being of child.

(OPEN TEXT)

Summarize how the home study assessment addressed the concerns of the referral and the reason for referral noted in the Reason for Referral section.

(OPEN TEXT)

Summarize any new concerns raised during the home study.

(OPEN TEXT)

How can these issues or concerns be mitigated and how much time is needed to address the concerns?

(OPEN TEXT)

Is there an active plan in place to address the above concerns? Yes No

If outstanding concerns are related to the child’s disability, what affirmative support and assistance should ORR provide to enable the child’s safe release?

Describe the post-release community-based services and supports the sponsor may need help accessing and address whether these services will help enable the child’s safe release. Not Applicable

(OPEN TEXT)

What are the potential benefits of releasing the child to this sponsor in this community setting?

(OPEN TEXT)

How equipped is the sponsor to advocate for the child to received necessary services?

Assessment Comments

(OPEN TEXT)

Recommendation

<Dropdown Menu> (-Select One- Positive Home Study Recommendation, Negative Home Study Recommendation)

Home Study Recommendation

Certification

HS/PRS Worker Printed Name (OPEN TEXT) Assessment Completion Date (OPEN TEXT)

HS/PRS Provider Supervisor (OPEN TEXT) Supervisor Review Completion Date (OPEN TEXT)

(OPEN TEXT)

Assessment Status

Verify and Submit Assessment to ORR

Date Submitted (OPEN TEXT)

Assessment Comments

(OPEN TEXT)

Table1: Dropdown Options for Sponsor Relationship to Child

Adult First Cousin (Non-Primary Caregiver) Adult First Cousin (Primary Caregiver) Adult Nephew (Non-Primary Caregiver) Adult Nephew (Primary Caregiver) Adult Niece (Non-Primary Caregiver) Adult Niece (Primary Caregiver) Aunt (Non-Primary Caregiver) Aunt (Primary Caregiver) Brother Brother-in-law (Non-Primary Caregiver) Brother-in-law (Primary Caregiver) Father Godfather Godmother Grandfather Grandmother Half-sibling Legal Guardian

Mother Other Distant Relative Sister Sister-in-Law (Non-Primary Caregiver) Sister-in-Law (Primary Caregiver) Stepbrother Stepfather Legally Adopted Stepfather Non-Lgl Adopted (Non-Primary Caregiver) Stepfather Non-Lgl Adopted (Primary Caregiver) Stepmother Legally Adopted Stepmother Non-Lgl Adopted (Non-Primary Caregiver) Stepmother Non-Lgl Adopted (Primary Caregiver) Stepsister UC’s Spouse Uncle (Non-Primary Caregiver) Uncle (Primary Caregiver) Unrelated Sponsor

Table 2: Dropdown Options for Household Member Relationship to Child and Relationship to Sponsor
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 Stepparents Sister Sister-in-Law Son Son-in-law Sponsor’s Partner Stepdaughter Stepbrother Stepfather Stepmother Stepson Stepsister UC’s Spouse Uncle Unknown Unrelated

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow home study providers to document their assessment of a potential sponsor after performing a home site visit. 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, 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].

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Author	Herboldsheimer, Shannon (ACF)
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File Created	2025-05-29