Form S-15 Child Advocate Referral and Appointment

OMB 0970-#### [Valid through MM/DD/2020]

Office of Refugee Resettlement

U.S. Department of Health and Human Services Child Advocate Recommendation & Appointment Form

OFFICE OF REFUGEE RESETTLEMENT

Division of Unaccompanied Children’s Services

The William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008 section 235(c)(6) authorizes the Secretary of Health and Human Services to appoint “independent child advocates for child trafficking victims and other vulnerable unaccompanied children.” This appointment authority has been delegated to the Office of Refugee Resettlement (ORR). ORR will use this form to determine whether a Child Advocate shall be appointed and to document the Child Advocate’s appointment for UAC in ORR/DUCS care and custody.

Section 1 (To be completed by the initial referrer)

1. UAC information:

Name of UAC:      	A#:      
Date of birth:      	Nationality:      
Language(s) spoken by UAC:      	Current location:      
Name of referrer:      	Date of UAC’s arrival at care provider:      
Relationship of referrer to the UAC:      	Date of referral:      

B. Checklist (please check all that apply)

Is between the ages of 0-12

Is placed in a residential treatment center or therapeutic facility

Is pregnant or parenting

Has a physical or mental disability

Is a national from a country known to traffic children

Has been identified as a possible child trafficking victim (Interim Assistance Letter, Eligibility Letter, etc.)

Has a criminal or delinquency history and/or is placed in a staff secure care provider or secure care provider, and there are outstanding issues impacting the UAC’s release or discharge plan

Has been a victim of a crime

Is not proficient in a language spoken by staff at the UAC’s care provider, and for whom there is no accessible interpreter routinely available

Will turn 18 in less than six (6) months of placement and for whom family reunification is unlikely

Is identified as being eligible for legal relief

Has a credible fear of returning to their country of origin and/or are seeking voluntary departure despite concerns about their safety in their home country

Lacks appropriate legal representation, or for whom there is a good faith belief that the child’s legal representative has ties to child trafficking or criminal activity

Is expected to have a protracted stay of over 120 days in ORR/DUCS custody

Whose potential sponsor is undergoing a home study

Is unable to make an independent decision

Any other case where the UAC is considered to be exceptionally vulnerable. Explain here:      

Section 2 (To be completed by the child advocate program)

A. Does your program recommend that ORR appoint a Child Advocate, and is an individual Child Advocate available for this UAC based on the criteria selected?

Yes.

No. If no, explain here:      

More information needed. Explain here:      

B. Name of child advocate program official making the recommendation:

(name)       (date)      

C. Name of the individual Child Advocate identified for assignment:      

Section 3 (To be completed by ORR/DUCS)

1. Is the recommendation for the appointment of a Child Advocate approved for the above named UAC?:

Yes.

No. If no explain here:      

B. Signature of ORR/DCS Division Director:

________________________________ (date)      

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 and other stakeholders to recommend appointment of a child advocate for a UAC. Public reporting burden for this collection of information is estimated to average 0.25 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 UACPolicy@acf.hhs.gov.