Form S-11 UC Assessment - UC Path Version

UC Assessment (Form S-11)
Data Entry Window

UC Assessment Page – Basic Information Tab

[PHOTO]

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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

UC Assessment Page – Relationships Tab – Family and Friends

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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

UC’s Children Data Entry Window

Friends and Family Data Entry Window

UC Assessment Page – Relationships Tab – Sponsor Information

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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

Adult Contact Relationships Data Entry Window

UC Assessment Page – Criminal 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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

Criminal Charges Data Entry Window

UC Assessment Page – Trafficking 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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

UC Assessment Page – TVPRA 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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

UC Assessment Page – Documents 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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]

Documents Data Entry Window

UC Assessment Page – Certification 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 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 2 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 UCPolicy@acf.hhs.gov.
UC-S-11 [Rev. MM/DD/YYYY]