Form S-19 HS-PRS Referral - UC Path Version

Home Study/Post-Release Service Referral (Form S-19)
Data Entry Window

Dropdown Options:
Pending
Closed
Cancelled
HS/PRS Referral Initiation
Active
Dropdown Options:
Imminent Age Out
Length of Time Since Referral
Tender Age
Other

Dropdown Options:
Yes
No
Dropdown Options:
Sponsor is unavailable
UC Returned to Home Country
UC is no longer in the home
Age Out
Other

Dropdown Options:
UC turned 18
Legal Case- Status Achieved
Legal Case- Closed without Status
Sponsor Declined Services
PRS Assessment deemed services
completed/no longer needed
Unable to Contact Sponsor/UC
Transferred to another PRS Provider
UC Ran Away
UC Arrested
Other
Dropdown Options:
Positive
Negative

OMB 0970-0553 [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow care providers to refer UC for a home study and/or post-release
services. Public reporting burden for this collection of information is estimated to average 0.33 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, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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 UCPolicy@acf.hhs.gov.
UC-S-19 [Rev. MM/DD/YYYY]

HS/PRS Referral Page – Details Tab

Dropdown Options:
Phone
Email
In-Person

OMB 0970-0553 [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow care providers to refer UC for a home study and/or post-release services. Public reporting burden for this
collection of information is estimated to average 0.33 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, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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 UCPolicy@acf.hhs.gov.
UC-S-19 [Rev. MM/DD/YYYY]

Entry Team – Add Member Data Entry Window

Dropdown Options:
Assistant Lead Case Manager
Assistant Lead Clinician
Attorney
Case Coordinator
Case Manager
Clinician
Contractor Field Specialist
Direct Care Worker
Direct Operations Coordinator
Federal Field Specialist
Federal Field Specialist Supervisor
HS/PRS Primary Provider
HS/PRS Subcontractors
Lead Case Manager
Lead Clinician
Medical Coordinator
Program Support Staff
Read Only
Supervisor
Supervisory Case Coordinator

HS/PRS Referral – Related Tab

OMB 0970-0553 [valid through MM/DD/YYYY]
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow care providers to refer UC for a home study and/or post-release services. Public reporting burden for this collection
of information is estimated to average 0.33 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, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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 UCPolicy@acf.hhs.gov.
UC-S-19 [Rev. MM/DD/YYYY]