Form S-8 Initial Intakes Assessment

Services Provided to Unaccompanied Alien Children

TAB F - Initial Intakes Assessment (Form S-8)

Initial Intakes Assessment (Form S-8)

OMB: 0970-0553

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Initial Intakes Assessment

OMB 0970-#### [Valid through MM/DD/2020]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to screen
UAC for trafficking or other safety concerns, special needs, danger to self and others, medical conditions, and mental health concerns. Public reporting burden for this collection
of information is estimated to average 0.25 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). 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 UACPolicy@acf.hhs.gov.

Vomiting

Yes

No

Abdominal Pain

Yes

No

Coughing Blood

Yes

No

Nausea

Yes

No

Skin lesions/rash

Yes

No

Severe/persistent headache

Yes

No

Jaundice (Yellowing of the skin/whites of eyes)

Yes

No

Neurological symptoms (Spasm, tics, uncontrollable movements,
paralysis or numbness of any part of the body)

Yes

No

Others(list)

Yes

No

If Yes, specify:

If injuries, wounds, bruises present, describe them and how they occurred:
List of other medical concerns:
Have you ever been to a doctor or stayed in a hospital?

Yes

No

Yes

No

Yes

No

Yes

No

If yes, please list any visit or stay for any reason. Also include visits to other healers or alternative treatment providers:
Do you have a history of tuberculosis?
If yes explain:
Do you have a history of seizures of convulsions?
If yes explain:
Do you have any scars, birthmarks, or tattoos?
If yes explain:
Mental Health (Check all that apply)

If the child answered “Yes” to any of the below mental health questions and/or if any concerning behaviors or emotions were observed or reported, immediately report
your concerns to the Clinician, Lead Case Manager, Program Director, or Shift Supervisor for further guidance on the need to seek mental health care.
Concern

Yes/NO

Tried to hurt yourself?

Yes

No

Had urges to beat, injure or harm someone?

Yes

No

Harmed anyone?

Yes

No

Thought of attempting suicide or hurting yourself?

Yes

No

Attempted suicide?

Yes

No

Heard voices that others do not?

Yes

No

Seen things or people that others do not see?

Yes

No

Had trouble controlling anger or violent behavior?

Yes

No

Are you having thoughts of harming yourself or someone else?

Yes

No

Please explain any checked answers above:
Observable emotional concerns (Check all that apply)

Concern

Yes/NO

Cooperative

Yes

No

Uncooperative

Yes

No

Alert

Yes

No

Distracted

Yes

No

Calm

Yes

No

Excited

Yes

No

Nervous

Yes

No

Agitated

Yes

No

Confused

Yes

No

Sad

Yes

No

Angry

Yes

No

Other

Yes

No

 

If Yes, specify:

Are you having thoughts of harming yourself or someone else?
Safety Assessment

If the child answered “Yes” to any of the below safety assessment questions, immediately report concerns to the Clinician, Lead Case Manager, Program Director, or
Shift Supervisor for further guidance on how to ensure the child’s safety.
Do you feel safe now?

Yes

No

Yes

No

Explain if No:
Do you fear that someone will harm you?
Explain if yes:
Explain to the child where the child’s room will be located in the facility, the number of potential roommates, the age and sex of the roommates, and the bathroom and shower area

associated with the potential room assignment. After having explained this, does he or she identify any specific fears about this potential housing assignment?
Do you need anything right now?

  INTERVIEWER SUMMARY OF CRITICAL ISSUES THAT NEED IMMEDIATE  
ATTENTION:
List any issues rated above as urgent or significant and your actions to address them.
Deliver this form to the Lead Case Manager, Clinician, or other SUPERVISOR
designated to follow-up care.
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ACTIONS TAKEN: 
Each action should correspond to the issues noted at left.

Staff Signature:

Date:

Staff Name:

Staff Title:

Translator's Signature:

Date:

Translator's Name:

Language:

Yes No


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