Unaccompanied Alien Children – Coronavirus (COVID-19) Risk Questionnaire

OMB #: 0970-0XXXX

Expiration Date: XX/XX/XXXX

Unaccompanied Alien Children – Coronavirus (COVID-19) Risk Questionnaire

Instructions: This questionnaire presents a screening framework to evaluate Unaccompanied Alien Children (UAC) program staff and visitors for COVID-19 risk factors prior to entering ORR programs. If an individual selects ‘Yes’ for one or more of the questions below, please restrict access to the program; refer to the “Actions” section for further guidance.

Questions:

1. Are you currently experiencing any signs and symptoms of an acute respiratory illness (fever, cough, or shortness of breath)?

YES □ NO □

2. Have you had contact with someone known to have COVID-19 or who is under investigation for COVID-19?

YES □ NO □

3. Within the last 14 days, have you traveled to an international area with sustained transmission (China, Iran, South Korea, most of Europe)?

YES □ NO □

*A current list of international areas with sustained transmission can be found at: https://www.cdc.gov/coronavirus/2019-nCoV/hcp/clinical-criteria.html

Actions:

Staff

• If the response to Question 1 is ‘Yes’, access to the facility should be restricted. The staff member must be medically evaluated and cleared by their healthcare provider prior to returning.

• If the response to Question 2 or 3 is ‘Yes’, access to the facility should be restricted. The staff member must contact the local public health department for further guidance prior to returning.

Visitor

• If the response to Question 1 is ‘Yes’, access to the facility should be restricted. Facility staff should recommend that the visitor contact their healthcare provider.

• If the response to Question 2 or 3 is ‘Yes’, access to the facility should be restricted. Facility staff should recommend that the visitor contact the local public health authority. If the visitor returns within 14 days, facility staff should contact the local public health authority to seek additional guidance.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to evaluate UAC program staff and visitors for COVID-19 risk factors prior to entering ORR programs. Public reporting burden for this collection of information is estimated to average 3 minutes per response per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is highly recommended in order to ensure the health and safety of UAC and program staff. 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. The OMB # is 0970-0XXX and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact uac_covid-19@acf.hhs.gov.  

https://www.cdc.gov/coronavirus/2019-ncov/healthcare-facilities/guidance-hcf.html

https://www.cms.gov/medicareprovider-enrollment-and-certificationsurveycertificationgeninfopolicy-and/qso-20-14-nh.pdf