Form S-26 Form S-26 Home Study Referral

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

Administration for Children and Families

Office of Refugee Resettlement

Home Study Referral (Form S-26)

UAC Portal Version

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)

Home Study Case Referral
All fields required to submit a referral.
□ TVPRA □ ORR-Mandated □ Discretionary
Referral ID:		SYSTEM GENERATED	Referral Status:			SYSTEM GENERATED
Acceptance Date:		SYSTEM GENERATED	Expected Closure Date:			SYSTEM GENERATED
Referring Facility Information
Referring Facility Name:	(Auto Populate)			Alternative Email:	(Open Text)
Case Manager Name:	(Auto Populate)			Case Manager Email:	(Auto Populate)
Unification Specialist Name:	(Auto Populate)			Unification Specialist Email:	(Auto Populate)
Sponsor Information
Sponsor Name:	(Auto Populate)			Sponsor Category:	(Auto Populate)
Sponsor City:	(Auto Populate)			Sponsor State:	(Auto Populate)
Sponsor Zip Code:	(Auto Populate)			Primary Sponsor:	(Auto Populate)
Sponsor Phone Number:	(Auto Populate)			Sponsor Relationship to Child:	(Auto Populate)
Sponsor Email:	(Auto Populate)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR grantee case managers to refer a child for a home study. 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. The OMB control number is 0970-XXXX and the expiration date is MM/DD/YYYY. If you have any comments on this collection of information, please contact [email protected].

Referral Information
Expedited:		□ No □ Yes
Reason Expedited:		<Single-Select Dropdown Menu> High Length of Care Age Out Other		Specify:		(Open Text)
Special Instructions:		<Single-Select Dropdown Menu> RTC Placement Medically Fragile Pregnant Parenting Tender Age Sibling Group Related		Additional Details:		(Open Text)
Reason for Referral:		<Single-Select Dropdown Menu> Victims of Trafficking (TVPRA) American Disability Act (TVPRA) Physical or Sexual Abuse (TVPRA) Sponsor Risk (TVPRA) 12 and Under Going to Non-Relative Sponsor (ORR Mandated) Non-Relative Sponsor Multiple Sponsorship (ORR Mandated) Child Going to Non-Relative Sponsor (ORR Mandated) ORR Discretionary
Cross-Referenced Case:
Relationship Group ID:
SYSTEM GENERATED
>| Save	>| Send Case Referral		>| Close Case Referral1		>| Cancel Case Referral2		>|Reset

Document Upload					Cancel Referral		Close
File to Attach:	<Auto-Populate File Upload Address Bar>				Reason for Cancellation:	(Open Text)
>| Upload		>| Cancel			>| Save

1 CONDITIONAL LOGIC: When “Close Case Referral” is selected, the Document Upload window opens

2 CONDITIONAL LOGIC: When “Cancel Case Referral” is selected, the Cancel Referral window opens

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S-26 | Version #

MM/DD/YYYY