Form S-11 UAC Assessment

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

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to
inform provision of services (e.g., case management, legal, education, medical, mental health, home studies), screen for trafficking or other safety concerns, and
identify special needs. Public reporting burden for this collection of information is estimated to average 0.75 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.

Family and Family Friends in the U.S.
Name

Age

DOB

Relationship
-- Select Relationship --- Select Relationship --- Select Relationship --- Select Relationship --- Select Relationship --

Parent’s whereabouts?
Are you married?

Yes

No

Yes

No

Spouse Name, Age, and Location:
Has Children? (If yes, list below)
Children
Name of Child

Age

DOB

Current Location

Have you ever been hurt, physically, mentally or emotionally by someone taking care of you?

Name of Mother/Father
Yes

No

Yes

No

If yes, who and when?
Have you ever been taken to the hospital/emergency room because you were hurt?
If yes, explain:
What does the word “discipline” mean to you?
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

Cardiac Issues

Yes

No

Sexually Transmitted Disease

Yes

No

Respiratory/Lung Disorder

Yes

No

Physical Disability

Yes

No

Date of Diagnosis/Clarification

Medication History
Medication

Dosage

Timeframe

Medical Condition
Education

What is the highest level of education you have completed?
When was the last time you were in school? What age?
Legal
Know Your Rights Presentation
provided?

Yes

No

Yes

No

When?:
Legal screening completed?
When?:

Notice to appear filed?

Yes

No

Yes

No

When?:
Scheduled for hearing?
When?:
State:

-- Select a State --

Outcome:

Select Outcome

Has Attorney?

Yes

No

Yes

No

City:

Date of Meeting:
Any possible legal relief
identified?
Specify:

Criminal History
Any Criminal history? (If yes, list
below)

Yes

No

List any Felony convictions:
List any Misdemeanor convictions:
List any Probation/Parole:
List and describe any disclosed criminal activity:
Additional information:
History of Incarceration
Crime

Length of
Sentence

Date

Location

Mental Health/Behavior
Mental Status Evaluation
Attitude

Calm and Cooperative

Other

If other, describe:  

Behavior

No Unusual Movements or Psychomotor Changes

Other

If other, describe:  

Speech

Normal Rate/Tone/Volume

Other

If other, describe: 

Affect

--- Please Select --- 
If other, describe:

Mood

--- Please Select --- 
If other, describe:

Thought Process

Goal-oriented and Logical

Disorganized

Other

If other, describe: 

Thought Content

Suicidal Ideation

Homicidal Ideation

None Passive Active
If active:
Plan
Yes
No

None
If active:

Intent

Yes

Means

Yes

Orientation

Plan

Yes

No

Intent

Yes

No

No

Means

Yes

No

No Hallucinations or Delusions During Interview
Time

Place

Person

Other

Self

If other, describe: 

Memory/Concentration

Short term intact 

Long term intact 

distractible/Inattentive 

If other, describe: 

Insight/Judgment

Good

Fair

Active

No

--- Please Select --- 
If other, describe:

Perception

Passive

Poor
Mental Health

Have you ever talked to a psychiatrist, psychologist, therapist, social worker or counselor about an emotional problem?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

When:     

Have you ever felt you needed help with your emotional problems, or have you had people tell you that you should get help for your
emotional problems?
When:     
Have you ever been advised to take medication for anxiety, depression, hearing voices or for any other emotional problems?
When:     

Have you ever been seen in a psychiatric emergency room or been hospitalized for psychiatric reasons?
When:     

Have you ever heard voices no one else could hear or seen objects or things that others could not see?
When:     

Have you ever been depressed for weeks at a time, lost interest or pleasure in most activities, had trouble concentrating and
making decisions or thought about killing yourself?
When:     

Did you ever attempt to kill yourself?
When:     

Have you ever had nightmares or flashbacks as a result of being involved in some traumatic/terrible event? For example, warfare,
gang fights, fire, domestic violence, rape, murder, accident, being killed.
When:     
Have you ever given in to an aggressive urge or impulse on more than one occasion that resulted in serious harm to others or led
to the destruction of property?
When:     
Substance Use History
Substance

Used (even once)

Alcohol

Yes

No

Marijuana

Yes

No

Cocaine

Yes

No

Other Stimulants (Meth, Ritalin,
etc)

Yes

No

Heroin

Yes

No

Other Opiates (Oxycodone,
Morphine, etc)

Yes

No

Nicotine

Yes

No

Frequency of Use

Trafficking
Who planned/organized your journey?
Did a family member or family friend pay for your travel to the U.S.?

Yes

No

Yes

No

Yes

No

What were you told about the arrangements before the journey?
Did the arrangements change during the journey?
If yes, how?
Does your family or family friend owe money to anyone for the
journey?
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

Yes

No

Yes

No

If yes, who made the threats?
Were you ever physically harmed?
If yes, how?
Was anyone around you ever physically harmed?

Date of Last
Use

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

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

If yes, where?
Did anything bad happen to anyone else in this situation or anyone
else who tried to leave?
What happened and to whom?
Did anyone ever keep/destroy your documents?
If yes, who and what?
Did anyone ever threaten to report you to the police/immigration?
If yes, who?
Are you worried anyone might be trying to find you?
If yes, who?
Debt Bondage/ Labor Trafficking
Did you perform any work or provide any services?

Yes

No

Is there a debt?

Yes

No

If yes, has any debt amount increased?

Yes

No

Yes

No

Yes

No

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?

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

Yes

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

No

If yes, date of trafficking referral:      

Sponsor Information (List by Priority)
Current Sponsor

Cat (1,2,3)

Sponsor Name

DOB

Address

Phone

Legal Status

Relationship

Sponsor Risk Assessment
Substance use concerns?

Yes

No

Yes

No

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:
Does the sponsor have adequate housing?
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:
Crime

History of Incarceration:
Are there any parent/child relational issues?

Date

Location

Length of Sentence

Yes

No

Yes

No

Yes

No

If yes, explain:
Does the sponsor have an Order of Removal?
If yes, date issued:
Has the sponsor sponsored any other UAC in DCS care?
Additional sponsor information:
Sponsor Sponsored UACs:

Name of UAC

A Number

Relationship

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 UAC.)
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)?
If yes, specify disability:       

Yes

No

Yes

No

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?

Yes

No

Yes

No

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 UAC?
If yes, provide a short summary:      
Additional Information
Please input any additional information if needed:

Certification
Signature:

Date:
Print Name:
Title: