Form 1 Care Provider Family Reunification Checklist

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services

OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
CARE PROVIDER FAMILY REUNIFICATION CHECKLIST
IDENTIFYING INFORMATION
Child’s name:
Child’s Date of Birth:
Child’s date of admission to ORR:
Date DHS notified of discharge:
Discharge date:
A#:
RELEASE RECOMMENDATIONS

Sponsor’s name:
Date sponsor identified:
Is this the first identified sponsor for this UC to undergo the release process?
If “NO” to the above question, how many other sponsors have undergone the release
process?

Release Request (Case Manager)
Release Request (Case Coordinator)
Release Request Decision (ORR/FFS)
UC ASSESSSMENT AND ISP (ensure documented in UC Portal)

Target
Date

Actual
Date

Target
Date

Actual
Date

UC Assessment
ISP
UC provided “Know Your Rights” presentation (video or LSP in-person)
UC Case Review, if applicable
SPONSOR SUPPORTING DOCUMENTATION AND INFORMATION (ensure documented in UC Portal)
Family Reunification Packet sent to sponsor
Completed Family Reunification Packet (and supporting documentation and forms) received:
Safety Plan, if applicable
Signed Family Reunification Application
Proof of sponsor’s identification:
(name document(s) used)
Copy of sponsor’s birth certificate:
(name document(s) used)
Proof of child’s identification:
(name document(s) used)
Signed Authorization for Release of Information
Court records or other reports for the sponsor, is applicable
(name document(s) used)
Proof of relationship between child and sponsor, if applicable:
(name document(s) used)
IF A NON-PARENT/NON-LEGAL GUARDIAN Letter of Designation for Care of a Minor, not required but check if
Sponsor received and is informed of its importance for caring for the UC post release.
IF A NON-PARENT/NON-LEGAL GUARDIAN Proof of address:
(name document(s) used)
Additional documentation on sponsor as relates to release assessment:
(name document(s) used)
BACKGROUND CHECKS (ensure documented in UC Portal)

Date
Reques
ted

Date
Received

Sponsor Fingerprint appointment scheduled, if applicable (indicate date of appointment under DATE RECEIVED)
Sponsor National Criminal History (fingerprint) Check, if applicable
Sponsor Immigration Check, if applicable
Sponsor Internet Criminal Public Records Check
Sponsor Child Abuse and Neglect Check, if applicable
Sponsor State Criminal History Repository Check and/or Local Police Check, if applicable
Sponsor FBI Interstate Identification Index (FBI III) Name/Descriptor Check, if applicable
Household Members National Criminal History (fingerprint) Check, if applicable
Household Immigration Check, if applicable
Household Sponsor Internet Criminal Public Records Check, if applicable
Household Members Child Abuse and Neglect Check, if applicable
Household State Criminal History Repository Check and/or Local Police Check, if applicable
Household FBI Interstate Identification Index (FBI III) Name/Descriptor Check, if applicable
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .10/
hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An
agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control
number.

U.S. Department of Health and Human Services

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

HEALTH SERVICES (Enter all medical results and upload medical and immunization documents in UC Portal)

Actual
Date

Initial medical exam form completed
TB screening, following age-specific initial medical exam requirements
HIV testing for children ≥13 years (document if UC opts out of testing)
Pregnancy testing for eligible females (test prior to administration of vaccines; defer live vaccines during pregnancy)
Lead screening for children 6 months-6 years old
Immunizations, according to the ACIP catch-up schedule
Follow-up laboratory tests and consultations completed, as indicated
Child clear of all contagious conditions, including scabies and lice
Child or sponsor provided with copy of all health records, including medical, mental, dental, medication, and immunization
records
HOME STUDY AND POST-RELEASE SERVICES CASES ONLY SUPPLEMENT
HOME STUDY CASES
Date referred to ORR HQ for Home Study
Date ORR HQ verified referral acceptance and name of Home Study provider:
Home visit completed
Completed Home Study submitted to ORR
Case Manager’s release recommendation, following completion of Home Study
Case Coordinator’s release recommendation, following completion of Home Study
ORR/FFS release decision, following completion of Home Study
POST-RELEASE SERVICES CASES

Actual
Date

Actual
Date

Date referred to ORR HQ for Post-Release Services
Date ORR HQ verified referral acceptance of Post-Release Services provider were in place and name of Post-Release Services
provider:

CASE MANAGER AFFIRMATION (DONE AT TIME OF CASE CLOSING, TRACKING AND REPORTING)
Per Ops Guide Section 2 Safe and Timely Release and Section 3 Assessments
I declare and affirm that the information contained in this checklist is true and accurate to the best of my knowledge including all
dates upon which the required documents were submitted or produced by the care provider. I attest that all dates on this
checklist are accurate and that the release recommendations, ISP, UC Assessment, UC Case Review, Family Reunification
Application, applicable supporting documentation, background check documents, child assessments, Discharge Notification and
documentation, and if necessary Home Study and/or Post-Release Service information have been completed by the appropriate
party, and that if requested I can produce all documents on demand as required by law and applicable ORR UC program policies
and procedures. I have noted below and given an acceptable explanation as to why not all documents or supporting
documentation was submitted.
List required documentation not available and explanation:
SIGNATURE OF CASE MANAGER:
DATE:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .10/
hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB
control number.