Form P-12C Program Entity

Program Entity (Form P-12C)

DETAILS

Program Overview

Program Status		Program Name AKA
Type		Program ID
Address		Country
Street		City
State		Zip/Postal Code
ACF Region		Within ORR Network?	Yes/No
FFS Region		VOLAG Grantee?	Yes/No
UC Drop-Off Information		URM Program?	Yes/No
Maximum Months Pregnant		Confirmed? ¨

Points of Contact

CEO		CEO Email
		Phone
Program Director
Intakes Primary Contact		Intake Primary Contact Email
		Intakes Primary Contact Phone
Program Medical Team Email		FFS Email

Stakeholder Information

Child Advocate		Legal Service Provider
FOJC

Influx and Variance Bed Capacity

Undelivered Warm Status		Delivered Variance Beds
Undelivered Reserve Status		Undelivered Variance Beds

License

Licensed?	Yes/No	License Issued Date
Licensing Entity		License Expired Date
License Type		Copy of Lease Uploaded? ¨
Licensing POC #1		Licensing POC #1 Email
		Licensing POC #1 Phone
Licensing POC #2		Licensing POC #2 Email
		Licensing POC #2 Phone
Licensing POC #3		Licensing POC #3 Email
		Licensing POC #3 Phone

Grant

Grant Number		Secondary Grant Number
Current Grant Project Start Date		Current Grant Project End Date
Current Grant Budget Start Date		Current Grant Budget End Date
Initial Grant Award Date		Closure Date
Initial UC Placement Received Date		Closure Date Reason

Stop Placement

Stop Placement (Initial)	Yes/No	Anticipated End Date (Initial)
Stop Placement Reason (Initial)		Start Date (Initial)
		End Date (Initial)
Stop Placement (Transfer)	Yes/No	Anticipated End Date (Transfer)
Stop Placement Reason (Transfer)		Start Date (Transfer)
		End Date (Transfer)

Monitoring Details

Last Monitoring Date		First Admitted Date
Due Date for Next Monitoring Visit		Number of Sites
Monitoring Schedule Notes

System Information

Program Legacy ID

Facility Legacy ID

RELATED

Entity Team

Team Member	Member Role	Entity Access Level	Entry Access Level	UC Access Level

Facility Information

Title	Original Document Name	Record Type	Document Type	Description	Date Received	Created By	Created Date

Operational Information

Title	Original Document Name	Record Type	Document Type	Description	Date Received	Created By	Created Date

Compliance Information

Title	Original Document Name	Record Type	Document Type	Description	Date Received	Created By	Created Date

Entity History

Date	Field	User	Original Value	New Value

Beds

Bed Name	Proposed Delivery Date	Actual Delivery Date	Last Modified Date	Last Update by Alias

Funded Capacity Manager

How many delivered male beds?		How many undelivered male beds?
How many delivered female beds?		How many undelivered female beds?

OMB 0970-0554 [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 ORR to track certain information related to its care provider programs, such as location, contact information, state licensure, grant information, and monitoring. Public reporting burden for this collection of information is estimated to average 0.17 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.

P-12C [Revised MM/DD/YYYY]

Dropdown Options

Program Status	Active Inactive Draft
Type	Influx Care Facility Long Term Foster Care LTFC – Community Placements LTFC – Group Home Residential Treatment Center Secure Shelter Staff Secure Therapeutic Group Home Therapeutic Staff Secure Therapeutic Foster Care Emergency Intake Sites Other
Country	List of all countries
State	List of all states and the District of Columbia
ACF Region	1 2 3 4 5 6 7 8 9 10
FFS Region	Arizona Central Texas Houston/El Paso Mid-Atlantic Mid-West North East Rio Grande Valley South East Special Population West Coast
Maximum Months Pregnant	Month 1: Weeks 1 to 4 Month 2: Weeks 5 o 8 Month 3: Weeks 9 to 13 Month 4: Weeks 14 to 17 Month 5: Weeks 18 to 22 Month 6: Weeks 23 to 27 Month 7: Weeks 28 to 31 Month 8: Weeks 32 to 35 Month 9: Weeks 36 to 40
Licensing Entity	List of licensing entities for all states in which ORR operates care provider programs
License Type	List of all license types offered by the licensing entities available under the Licensing Entity Field, as applicable to ORR care provider programs
Stop Placement (Initial) and Stop Placement (Transfer)	Imminent risk of harm to or safety of UC Imminent risk of harm to or safety of staff Law enforcement agency recommendations to cease new referrals Identified risk is not related to one staff or incident, and cannot be corrected by the corrective action Active CPS licensing investigation involving staff, UC or both Grantee repeated non-compliance with ORR policies and procedures which impacts service to UC Shortage of staff Staff related incident Consistent pattern of UC running away Affected by natural disasters/evacuation Power outage Fire incident Isolation/Medical Concerns Request by the facility Other (provide details)
Team Member Role	This is a global picklist used across multiple forms that contains all roles. Appearance of a role on this list does not mean that role will be granted access to this form. Assistant Program Director Attorney Case Coordinator Case Manager Child Advocate Contact Clinician Contractor Field Specialist DHUC Medical Team Member DHUC Quality Assurance Specialist Direct Operations Coordinator DOJ/FBI Federal Field Specialist HHS OIG HS/PRS Primary Providers ICE FOJC Influx POC Intakes Backup Contact Intakes Contact Lead Case Manager Lead Clinician Legal Service Provider LNO Medical Coordinator Medical Service Director On-site Health Care Provider ORR Compliance Team Program Director Program Support Center Project Officer PSA Compliance Manager PSA Program Specialist PSA Team Regional Director Registered Nurse Senior Advisor for Child Well-Being & Safety Shift Supervisor Supervisory Case Coordinator Supervisory FFS Supervisory Project Officer Temporary VOLAG User Program Support Staff
Entity Access Level	Read Only Read/Write
Entry Access Level	Read Only Read/Write No Access
UC Access Level	Read Only Read/Write No Access
Record Type/Document Type	Available Document Types are dependent upon what Record Type is selected. Facility Other Facility Intake List Program Brief Program Lease Signed Cooperative Agreement State Licensure Fire Inspection Emergency/Evacuation Plan Facility Floor Plan Operational Other Grantee Daily Schedule Internal SOPs Staff Training Curriculum Educational Curriculum Vocational Curriculum Food Menu UC Handbook/Orientation Prevention of Sexual Abuse/Harassment SOPs Organizational Chart Compliance Other ORR Closed Corrective Action ORR Closed Monitoring Report ORR Site Visit Report Program Licensing Investigation PSA Audit