Form 1 Transfer Request and Tracking Form

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .50/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:
Transfer request

Minor's Profile:
Height(ft & inches):

Weight(lbs):

Eye Color:
Identification Marks:
Transfer Request:
Type of Program Requested:

Requested Date:

Requesting Party:
Requester Name:
Requester Title:
Requester Phone:
Case Coordination:
Concur with Requesting

Yes

No

Party?
If not, specify:
Type of Program

Case Coordinator Proposed

Recommended:

Program:

Case Coordinator Name:
Recommended Date:
Reason for Transfer Request:
Shelter & Foster Care Only:

Secure & Staff Secure Only

Standard Placement

Convicted as Adult
Adjusdicated Delinquent
Criminal Charges
Chargeable

Any Program Type:

To provide a less restrictive setting (transfer only)

Disruptive Behavior

To provide a more restrictive setting (transfer only)

Minor's Safety

Minor's Medical Health

Flight Risk

Minor's Mental Health

Emergency Influx

Violent/Threatening Behavior

Has the Minor's Attorney
Been Contacted?

Yes

No

Attorney Phone:

Attorney of Record:
Casefile Summaries
Information Relating to

Pregnancy

Diagnosed Behavior/Illness with no Medications

Minor's casefile

Injury

Diagnosed Behavior/Illness with Medications

Illness

Non‐violent Conviction

Non‐diagnosed Behavior/Illness with no Medications

Non‐violent Charge

Non‐diagnosed Behavior/Illness with Medications

Charge(s) Dropped

Minor's Medical/Mental
Health Summary:
Behavior Summary: (history of: flight risk, aggressive/assaultive & sexually inappropriate behaviors)
Current Status of Family
Reunification:
Immigration Court Status:
Case Manager Comments
Case Manager Name:
Case Manager Comments:
Case Manager Suggests

Yes

No

Transfer?:

TMS Historical Transfer
Request?:

Date of Case Manager
Comments:
ORR/DCS Decision
Comments:
Decision:

Pending

Date of Decision:

Approve
Disapprove
Remanded, please provide info as detailed in comments

Name of ORR Decision Maker:
Transfer Packet (for each minor)
Please follow checklist in the Transfer Procedures when completing minor's transfer packet, check the checkbox to indicate the packet is completed.
List of Minor's Belongings (be sure to include medication and explain dosage in medical/mental health summary)
COA ‐ COV
Request Type

Change of Address

Transfer Sch. to Take Place on:

Change of Value
Next Sch. Court Appearance for
this Juvenile is:

Reason for less than 48 hours notice to ICE (if applicable) :
Good cause exists to change venue in this matter pursuant to 8 C.F.R. & 1003.20 (b) for the following reason(s);
ORR has decided to relocate the respondent to an area where space is available/ appropriate services can be provided, since Juvenile detention space is limited in
The minor has a special need (e.g., pregnancy of juvenile, medical needs, etc.), please specify 
Other, please specify 

Departure/Arrival Information
Departure Date:

Departure Time:

Transporting Staff Name:
Transporting Staff Title:
Transporting Staff Comments:
Arrival Date:
Receiving Staff Name:
Receiving Staff Title:
Receiving Staff Comments:

Arrival Time: