Form 1 UC Case Review

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average 1 hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
OMB Control No: 0970-XXXX; Expiration date: XX/XX/XXXX

UC Basic Information
First Name:
Last Name:
AKA:
Status:
Date of Birth:
A No.:
Age:
Country of Birth:

Gender:
LOS:
Current Program:
Admitted Date:
30 day Case Review

Discharge

Transfer

Are there any changes?:

Previous Placement:
test

Religious Affiliation:
test

Case Manager:
test

Clinician:
test

Document any new information regarding the UC not indicated in the UC Assessment and/or the previous case summary below
Medical
List any allergies:
Do you feel unwell?
Yes No

If yes, what are your symptoms?
Additional medical information:
Medical History

Condition

Yes/NO

Pregnant

Yes

No

Tuberculosis

Yes

No

Varicella

Yes

No

Measles

Yes

No

Mumps

Yes

No

Rubella

Yes

No

Asthma

Yes

No

Diabetes

Yes

No

Cancer

Yes

No

Yes

No

Yes

No

Cardiac
Issues

Date of Diagnosis/Clarification

Sexually
Transmitted
Disease

Yes

No

Respiratory/Lung
Disorder
Physical
Disability

Yes

No

Yes

No

Medication History
Medication

Dosage

Timeframe

Medical Condition

Legal
Know Your Rights Presentation

Yes

No

Yes

No

Yes

No

provided?
Date:
Legal screening completed?
Date:
Any possible legal relief identified?
Specify:
Mental Health
Provide a short summary of the UAC’s current functioning:

Psychological Evaluation
Date of Evaluation:
Evaluator:
Axis I:
Axis II:
Axis III:
Axis IV:
Axis V:
Summary of Recommendations:
Trafficking
Who planned/organized your journey?
What were you told about the arrangements before the journey?
Did the arrangements change during the journey?

Yes No

If yes, how?
Does your family owe money to anyone for the journey?

Yes No

If yes, how much?
Whom is the money owed?
Who is expected to pay?
What do you expect to happen if payment is not made?
Coercion Indicators
Did anyone threaten your or your family?

Yes No

If yes, who made the threats?
Were you ever physically harmed?

Yes No

If yes, how?
Was anyone around you ever physically harmed?

Yes No

If yes, who?
Were you ever held against your will?

Yes No

If yes, where?
Did anything bad happen to anyone else in this situation or anyone else who tried to leave?

Yes No

What happened and to whom?
Did anyone ever keep/destroy your documents?

Yes No

If yes, who and what?
Did anyone ever threaten to report you to the police/immigration?

Yes No

If yes, who?
Are you worried anyone might be trying to find you?

Yes No

If yes, who?
Debt Bondage/ Labor Trafficking
Did you perform any work or provide any services?

Yes No

If yes, what and where?
Who arranged the work?
What type of work did you perform?
What was the work schedule?
Did work conditions change over time?
Is there a debt?
If yes, has any debt amount increased?

Yes No
Yes No

By how much?
When did it increase?
Why did it increase?
Have you or your family ever been threatened over payment or work for the journey?

Yes No

If yes, who threatened you and how?
What did you expect would happen if you left the job or stopped working?
Were you ever made to work or do anything you did not want to do?
Did you receive pay or did someone else keep the pay?

Yes No

Were you paid what was promised when you started working?
Were expenses taken out of the pay?

Yes No

If yes what?
How did you get to the work site?
Where did you live while working?
Commercial Sex Indicators
Did anyone ever ask you to see you naked or in your underwear in exchange for money/anything of value?

Yes No

Did anyone ever pay/accept money/anything of value from other people in order to see you naked or in your underwear?

Yes No

Did anyone ever ask to take pictures or recording of you naked or engaged in sex acts?

Yes No

If so, did they offer you money/anything of value to do this or did they accept money/anything of value from others in order to see these pictures or recordings?

Yes No

Did anyone ever ask or expect you to perform sexual acts in exchange for money/anything of value?

Yes No

Did anyone ever promise or give money or anything of value to you in exchange for sexual acts?

Yes No

Based on the information provided above in the “Trafficking” section, is there a trafficking concern?

Yes No

If yes, date of trafficking referral:
Sponsor Information (List by Priority)
Current Sponsor

Cat (1,2,3)

Sponsor Name

DOB

Address

Sponsor Risk Assessment Sponsor Risk Assessment
Substance abuse concerns?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If yes, explain:
Domestic violence concerns?
If yes, explain:
Child abuse or neglect concerns?
If yes, explain:
Mental health issues?
If yes, explain:
Does the sponsor have any family support?
Specify:
Does the sponsor have any identified special needs?
If yes, explain:
Does the sponsor have financial needs?
If yes, explain:

Phone

Legal Status

Relationship

Does the sponsor have adequate housing?

Yes

No

Yes

No

If yes, explain:
Are there any concerns with the disciplinary practices/philosophy of sponsor?
Does the sponsor have any criminal history?
List any Felony convictions:
List any Misdemeanor convictions:
List any Probation/Parole:
List and describe any disclosed criminal activity:
History of Incarceration:

Crime

Are there any parent/child relational issues?
If yes, explain:
Does the sponsor have an Order of Removal?
If yes, date issued:
Has the sponsor sponsored any other UC in DCS care?
Additional sponsor information

Sponsor Sponsored UCs:

Date
Yes

No

Yes

No

Yes

No

Name of UC

A Number

Length of Sentense

Relationship

Location

Facility sponsored from

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 UC.)

Yes No

Date eligibility letter issued:
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)?
Yes No

If yes, specify disability:
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?
If yes, provide a short summary:
Based on the sponsor risk assessment, does the sponsor clearly present a risk of abuse, maltreatment, exploitation, or trafficking to the UC?

Yes No

If yes, provide a short summary:
Yes No

Recommendations
Discharge:

Yes

No

Yes

No

Yes

No

Sponsor:
Discharge w/ Post Release:
Date of PR referral:
Refer to Home Study
Reason for HS referral:

Care Plan

Reunification:
Legal:
Mental Health:

Certification
Signature:
Date:
Print Name:
Title: