R-4 Release Request - UC Path Version

Release Request (Form R-4)
Data Entry Window
• CM Initiated
• CM to Provider Further
Information
• CC Review
• FFS Review
• HS Requested
• HS Completed – CM Review
• HS Completed – CC Review
• HS Completed – FFS Review
• ORR Initiated
• Case Consultation Process
• DNF Generated
• Inactive
• Completed

• Release to Sponsor
• Release to Program

• Influx Centralized Box
• Centralized Box
• CC Weekend
• CC Influx
• Yes
• No

Yes
No

• Yes
• No

• Final Eligibility
• Interim Eligibility
• Pending Notification
• Not Eligible

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No

• Yes
• No
• Yes
• No

• Approve Straight Release
• Approve with Post-Release Only
Services
• Deny Release
• Conduct Home Study- TVPRA
• Conduct Home Study- ORR
Mandated
• Conduct Home Study- Discretionary
• Approve Release Pending
Completion of Condition
• Conduct Home Study
• Approve with Post-Release ServicesAfter ORR Mandated
• Approve with Post-Release ServicesAfter TVPRA
• Approve with Post-Release ServicesAfter Discretionary
• Deny Release
• Approve with Post-Release Services
• Approve with Post-Release Services
Pending Completion of Conditions
• Recommendation PendingAdditional Information Needed

• Yes
• No
• Yes
• No

• Yes
• No
• Approve Straight Release
• Approve with Post-Release
Only Services
• Deny Release
• Conduct Home Study- TVPRA
• Conduct Home Study- ORR
Mandated
• Conduct Home StudyDiscretionary
• Approve Release Pending
Completion of Condition
• Conduct Home Study
• Approve with Post-Release
Services- After ORR Mandated
• Approve with Post-Release
Services- After TVPRA
• Approve with Post-Release
Services- After Discretionary
• Deny Release
• Approve with Post-Release
Services
• Approve with Post-Release
Services Pending Completion of
Conditions
• Recommendation PendingAdditional Information Needed

• HHM Refused to Provide ID
• Sponsor Withdrawal- Household
members unwilling to be
fingerprinted
• Sponsor Withdrawal- Unwilling to
reunify due to undocumented
status
• Sponsor Withdrawal- Failed to
pickup UC
• Sponsor Withdrawal- Lacks interest
and no longer calls the UC (Did not
formally inform staff of withdrawal)
• Sponsor Withdrawal- Not willing to
complete home study/post-release
service process
• Sponsor Withdrawal- Refused to
travel to pickup UC
• Sponsor Withdrawal- Arrested after
fingerprinting
• Sponsor- Arrested
• Sponsor- Deceased
• Sponsor Withdrawal- Other
• UC Discharge- Adult Status
• UC Discharge- Detained by local law
enforcement
• UC Discharge- Detained by US
Marshals
• UC Discharge- Ran Away
• UC Discharge- Adjustment of Legal
Status
• UC Discharge- Removed
• UC Discharge- Transferred
• Other- Administrative directive
• Other- Sponsor detained on way to
shelter
• Other- UC refused to reunify with
sponsor
• Criminal History
• Medical
• Care Plan Information for UC
• Case
Information/Assessment/Document
ation
• Rational for HS/PRS
Recommendation
• Sponsor Assessment Information
• Prior Sponsorship
• Other

• Positive
• Negative

• Yes
• No

• Approve Straight Release
• Approve with Post-Release Only
Services
• Deny Release
• Conduct Home Study- TVPRA
• Conduct Home Study- ORR
Mandated
• Conduct Home Study- Discretionary
• Approve Release Pending
Completion of Condition
• Conduct Home Study

• Yes
• No
• Sponsor not willing or able to
provide for child’s physical or
mental well-being
• Physical home environment
presents risk to safety or wellbeing
• Release of child presents risk to
self, sponsor, household, or
community
• Sponsor’s criminal history
• Household member’s criminal
history
• Sponsor’s substantiated
adverse child welfare findings
• Household member’s
substantiated adverse child
welfare findings
• Flight Risk (removal imminent)
• Other

OMB 0970-0552 [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 process recommendations and decisions for release of a UC from ORR custody. Public
reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and
0.33 hours per contractor case coordinator (a total of 0.75 hours), 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.
R-4 [Rev. MM/DD/YYYY]

Release Request Page

• Approve with Post-Release ServicesAfter ORR Mandated
• Approve with Post-Release ServicesAfter TVPRA
• Approve with Post-Release ServicesAfter Discretionary
• Deny Release
• Approve with Post-Release Services
• Approve with Post-Release Services
Pending Completion of Conditions
• Recommendation PendingAdditional Information Needed

OMB 0970-0552 [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 process recommendations and decisions for release
of a UAC from ORR custody. Public reporting burden for this collection of information is estimated to average 0.42 hours per grantee case manager and 0.33 hours per contractor case coordinator
(a total of 0.75 hours), 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 UACPolicy@acf.hhs.gov.
UAC-R-4 [Rev. MM/DD/YYYY]

Entry Team Data Entry Window

• Assistant Lead Case Manager
• Assistant Lead Clinician
• Attorney
• Case Coordinator
• Case Manager
• Clinician
• Contractor Field Specialist
• Direct Care Worker
• Direct Operations Coordinator
• Federal Field Specialist
• Federal Field Specialist Supervisor
• HS/PRS Primary Provider
• HS/PRS Subcontractors
• Lead Case Manager
• Lead Clinician
• Medical Coordinator
• Program Support Staff
• Read Only
S
i

Documents Data Entry Window

See table below.

•
•
See table below.

Yes
No

Dropdown options for “Record Type” and corresponding options for “Document Type”
Record Type
Proof of Relationship

Background Check
Case Coordination and Discharge
Case Management

Compliance Document
Compliance Forms
Education
FRP Forms
Facility Document
HS/PRS Document
Health Documentation

Legacy Document
Legal Document

Medical Document
Mental Health Documentation
Monitoring Visit

Operational Document
Other
Policy Guidance Documents
Profile Picture
Proof of Address
Proof of Financial Stability
Proof of Identity

Proof of Immigration Status or U.S. Citizenship
Referral Documents

Document Type
Birth Certificate – UC; Baptismal Certificate; Birth Certificate – Sponsor; Birth Certificate – Other; Consulate
Written Affirmation of Relationship; Verified by Government Agency/Consulate; Court Order – Adoption; Court
Order – Guardianship; Court Order – Other; Government Issued Photo ID; Government Issued Ration Card;
Hospital Record; Interview Notes; Land Deeds – Sponsor and UC’s Family; Letter of Designation for Care of a
Minor; Marriage Certificate; Passport (including stamps); Photographs; Remittance Receipts; School
Record/Diploma; Social Media Posts; Genogram; Other
FBI Criminal History and FBI Name Check
Verification of Release; Release Request; Discharge Notification; ORR Notice to ICE; and Notice of Transfer to ICE
Verification of Release; Release Request; Discharge Notification; ORR Notice to ICE; New Placement Orientation;
Safety Plan; Other; Medical Checklist; Transfer; Admission Assessment; Influx Transfer Facility Checklist; and
LTFC Memo

Other; ORR Closed Corrective Action; ORR Closed Monitoring Report; ORR Site Visit Report; Program Licensing
Investigation; and PSA Audit
Privacy 101; ROB; and Cybersecurity
Other, Initial Education Intake Assessment; ESL Assessment; Progress Report Card; and Educational
Reassessment Report
FRP 2 Authorization for Release of Information; FRP 3 Family Reunification Application; FRP 9 Letter of
Designation for Care of a Minor; and FRP 10 Sponsor Declaration
Other; Facility Intake List; Program Brief; Program Lease; Signed Cooperative Agreement; State Licensure; Fire
Inspection; Emergency/Evacuation Plan; and Facility Floor Plan
Addendum; Other Supporting Documents; and Post Release Assessment Report
Public Health Investigation Form; Hospital Discharge Instructions; Hospital Discharge Summary; Image Study
Reading (TB); Image Study Reading (Non-TB); Immunization Record; Initial Medical Exam Form; Initial Dental
Exam Form; Lab Results; Medications; Health Evaluation Form; Office Notes; Specialist Notes; Supplemental TB
Screening Form; and Other Health Document
All “Document Type” options available under other Record Types are available for this Record Type
Birth Certificate – UC; Court Order (Flores Bond); Court Order (Other); Court Order (Removal); Court Order (VD);
Decision (Administrative Review); Decision (Appeal of ORR Decision); Decision (Flores Bond Letter); Decision
(Specific Consent); DHS Document (I-213); DHS Document (NTA); DHS Document (Other); Form (Attorney of
Record); Form (Authorization for Release of Information); Form (Change of Venue); Form (Flores Bond Hearing
Motion); Form (Legal Resource Guide Part II – Admission); Form (Legal Resource Guide Part III – Release); Form
(Notice of Placement); Form (Specific Consent); Other Legal Document; OTIP Eligibility Letter; OTIP Interim
Assistance Letter; Placement Identification Document; Records (Court); Records (Criminal/Delinquency Records);
and Post Legal Status Plan
DHS Docs and Medical Checklist
Clinical Notes; Progress Notes; Discharge Summary; Psychiatric Evaluation Report; Psychological Evaluation
Report; RTC Recommendation Letter; Developmental Assessment Report; and Other Mental Health Document
Behavior Management Plan; Care Provider Policies and Procedures; Community Partnerships/Services; Cost of
Care; Education Documents; Emergency and Evacuation Plan; Fire and Safety Code Permits/Reports; Food
Services; Foster Home Safety Checklist; Foster Parent Agreement; Foster Parent Files; Foster Parent Orientation
Manual; Foster Parent Trainings; Full Staff List; Geographic Areas Served; Health/Sanitation Inspection Reports;
Independent Living Resources; List of Current Foster Parents; List of Home Study Cases; Map of Facility;
Memorandum of Understanding; Monitoring Schedule; Monitoring Tools and Instruments; Monitoring Visit
Reports; Mosquito Control Inspection; Organizational Chart; Quality Assurance Resources; Respite and Retention
Procedures; Site Visit Guide; Staff Trainings; Staffing Plan; State Licensing/CPS; UC Case Files; UC Orientation
Packet; UC with G-28s; and Vehicle Inspections
Other; Grantee Daily Schedule; Internal SOPs; Staff Training Curriculum; Educational Curriculum; Vocational
Curriculum; Food Menu; UC Handbook/Orientation; Prevention of Sexual Abuse/Harassment SOPs; and
Organizational Chart
DocGen; Placement Authorization; Medical Authorization; Notice of Placement; UC Assessments; New
Placement Orientation; Other; and Manifest
Policy Memo; Field Guidance; Interim Guidance; Form or Related Material; Frequently Asked Questions;
Procedure Manual; Other Guidance; Resource Material; and Training
Other
Current Lease or Mortgage Statement; Notarized Letter from Landlord; Utility Bill, Bank Statement; Payroll
Check Stub; Official Mail; Other Similar Document; and Letter/Code
Proof of Financial Stability
US Passport; US Passport Card; Foreign Passport; Permanent Resident Card; Alien Registration Receipt Card;
Employment Authorization Document; US Driver’s License or Identification Card; US Certificate of Naturalization;
US Military Identification Card; Birth Certificate; Court Order for Name Change; Foreign National Identification
Card; Consular Passport Renewal Receipt; Foreign Driver’s License; Foreign Voter Registration Card; Canadian
Border Crossing Card; Mexican Border Crossing Card; Refugee Travel Documents; Other Similar Government
Document; and Marriage Certificate
US Passport; Valid Visa; Legal Permanent Resident Card; Notice to Appear; Other Federal Government Document
Providing Immigration Status; US Birth Certificate; US Naturalization Papers; Court Order; and Other
Government Issued Document Proving US Citizenship
Birth Certificate – UC; Baptismal Certificate; DocGen; FRP 2 Authorization for Release of Information; FRP 3
Family Reunification Application; FRP 9 Letter of Designation for Care of a Minor; and FRP 10 Sponsor
Declaration; US Passport; US Passport Card; Foreign Passport; Permanent Resident Card; Alien Registration Card

Release Request
SIR/PLE Report Document
Self-Disclosed Criminal History
Sponsor Assessment

Receipt; Employment Authorization Document; US Driver’s License or Identification Card; US Certificate of
Naturalization; US Military Identification Card; Birth Certificate; Court Order for Name Change; Foreign National
Identification Card; Consular Passport Renewal Receipt; Foreign Driver’s License; Foreign Voter Registration
Card; Canadian Border Crossing Card; Mexican Border Crossing Card; Refugee Travel Documents; Valid Visa;
Legal Permanent Resident Card; Notice to Appear; Other Federal Government Document Providing Immigration
Status; US Birth Certificate; US Naturalization Papers; Court Order; and Other Government Issued Document
Proving US Citizenship; Birth Certificate – Sponsor; Birth Certificate – Other; Consulate Written Affirmation of
Relationship; Verified by Government Agency/Consulate; Court Order – Adoption; Court Order – Guardianship;
Court Order – Other; Death Certificate; Family Session Case Note; Government Issued Photo ID; Government
Issued Ration Card; Hospital Record; Interview Notes; Land Deeds – Sponsor and UC’s Family; Letter of
Designation for Care of a Minor; Marriage Certificate; Passport (including stamps); Photographs; Remittance
Receipts; School Record/Diploma; Social Media Posts; Genogram; Current Lease or Mortgage Statement;
Notarized Letter from Landlord; Utility Bill, Bank Statement; Payroll Check Stub; Official Mail; Other Similar
Document; Letter/Code; Proof of Financial Stability; Self-Disclosed Criminal History; Verification of Release;
Release Request; Discharge Notification; ORR Notice to ICE; Referral Documents; and Other
Best Interest Recommendation Letter; R-4 Release Request; ORR Denial Letter; Parent Denial Letter; Program
Acceptance Letter; Recommendation to Deny Release; Referral Services COO; Safety Plan; Travel Document;
Travel Itinerary; and Other
Police Report; State Licensing Documentation; Fraud Documentation; CPS Documentation; Significant Incident
Report; PLE Report; Other; DOJ/FBI Documentations; and HHS OIG Documentation
Self-Disclosed Criminal History
Initial and Final

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