Form S-12 UAC Case Review

UAC Case Review

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
document new information obtained after completion of the UAC Assessment. Public reporting burden for this collection of information is estimated to average
0.5 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.

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?
Yes No
If yes, has any debt amount increased?
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?
Yes No
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?
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)

DOB

Sponsor Name

Sponsor Risk Assessment Sponsor Risk Assessment
Substance use concerns?

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:

Address

Phone

Legal Status

Relationship

Does the sponsor have financial needs?

Yes

No

Yes

No

Yes

No

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?

Yes

No

Yes

No

Yes

No

Date

Length of Sentense

Location

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.)

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?

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:      
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:

Yes No