Form 1 Travel Request Form for UC Long Term Foster Care

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:
UC Long Term Foster Care Travel Request

Requester Information
Date of Travel Request:
Name and Contact Information of Individual Completing Travel Requests:
Name:
Telephone
Email :

(Travel Request form must be submitted to DUCS at least 10 business days prior to travel start date)

Travel Overview
Travel Begin Date:

Travel End Date:

Name of Individual child will be traveling with
Relationship to child:
Contact # while on travel:
Address where child will be staying while on travel
Mode of Transportation
Mode of transportation:
Include airline, flight #'s, bus company, train info as applicable:
Personal Vehicle Travel
Type of automobile: Make
Model:
License Plate
Car Insurance Company
Primary Driver: Name
Driver's license #:
Issuing state:
Approval Determination Factors
Reason travel request is being submitted to ORR/DCS for approval:
Is this travel request in accordance with state guidelines?
If no, please explain
Purpose of travel/trip summary
Child Supervision Plan
Are there any identified safety concerns in this child's background?

Policy Number:

Yes

No

Yes

No

If yes, please explain
Is there any indication of flight sick?

Yes

No

If yes, please explain
Comment
Date

Signature (ORR Official)