S-9 Assessment for Risk - UC Portal Version

Assessment for Risk

OMB 0970-0553 [Valid through 02/28/2021]

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
reduce the risk that a child or youth is sexually abused or abuses someone else while in ORR custody. 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.

If you click Yes above, please ask the following: Have you ever had a sexual experience that was not
consensual?
Explain:
9. Have you ever felt like you needed to perform sexual favors or allow someone to touch your body in a
sexual way in order to avoid additional harm, to obtain something you needed or wanted, or to be
accepted by a person or group of people?

Yes

No

Decline to Answer

Yes

No

Decline to Answer

Yes

No

Decline to Answer

If Yes, explain:

10.

Have you ever spoken to a counselor, social worker, psychologist, teacher, or any other adult because
of a sexual experience you had?
If Yes, explain:

INSTRUCTIONS: After interviewing the child or youth and reviewing relevant case files and other records, Clinicians and Qualified Case Managers must use their
professional opinion to answer the following questions.
QUESTIONS FOR CLINICIANS OR QUALIFIED CASE MANAGERS TO ANSWER
1. Does the child or youth exhibit any gender nonconforming appearance or manner?
If Yes, explain:

Yes

No

2. Does the child or youth have any current or past criminal charges?
If Yes, List the Charges and Explain:

Yes

No

3. Does the child or youth have any mental, physical, or developmental disability or illness or suspected of having any of the above?
 No
 Yes

Mental

Physical

Developmental

Mental

Physical

Developmental

Explain: n/a
 Suspected
Explain: n/a
4. What is the child’s physical size and stature?

Average

5. Other specific information that may indicate heightened needs and/or additional safety precaution:
If Yes, explain:

Yes

Smaller than Average

Larger than Average

No

INSTRUCTIONS: After completing the above assessment, determine if any housing and other service assignments are needed to ensure the safety and well-being of the child
or youth. Describe housing and other service assignments here. Indicate specific actions and follow-up. If housing and other service assignments are changed at any time,
including after the initial placement, describe the change and the reason for the change here.
HOUSING, OTHER SERVICE ASSIGNMENTS, AND FOLLOW-UP
1. Housing and Other Service Plan
2. If the child or youth identified as Transgender or Intersex, Click Here:
If you clicked the box, answer the following:
(a) The child or youth was placed in a room/dormitory that reflects the minor's preference

Yes

No

Yes

No

Explain:
(b) The child or youth was placed in educational or activities group(s) to reflect the minor's preference
Explain:
3. Actions Taken (Mark all that apply)
Clinician or Qualified Case Manager shared appropriate information with relevant care provider facility team
Explain:
Child or youth provided with psycho education on identified issue
Explain:
Child or youth provided with information on how to report threats, intimidation, or harassment by other children, youth, or facility staff
Explain:

Developed and implemented an in care safety plan between child or youth, clinician, and care provider staff to address a specific issue
Explain:

Child or youth provided with additional or alternate restroom accommodations
Explain:
Implemented increased clinical sessions
Explain:
Child or youth referred for professional/external mental health services
Date of Referral:
Explain:

Child or youth referred for medical services
Date of Referral: 
Explain:

Child or youth placed on closer staff supervision
Explain:
Staffed with FFS and CC for possible transfer
Explain:
Other
Explain:

Other Attachments

No specific action taken
Explain:

Staff Signature:

Date/Time:

Staff Name:
Staff Title:
Translator's Signature:
Translator's Name:
Language:

Date/Time: