Program Entity (Form P-12C)
DETAILS |
Program Overview |
Program Status |
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Program Name AKA |
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Type |
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Program ID |
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Address |
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Country |
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Street |
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City |
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State |
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Zip/Postal Code |
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ACF Region |
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Within ORR Network? |
Yes/No |
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FFS Region |
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VOLAG Grantee? |
Yes/No |
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UC Drop-Off Information |
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URM Program? |
Yes/No |
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Maximum Months Pregnant |
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Confirmed? ¨ |
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Points of Contact |
CEO |
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CEO Email |
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Phone |
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Program Director |
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Intakes Primary Contact |
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Intake Primary Contact Email |
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Intakes Primary Contact Phone |
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Program Medical Team Email |
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FFS Email |
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Stakeholder Information |
Child Advocate |
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Legal Service Provider |
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FOJC |
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Influx and Variance Bed Capacity |
Undelivered Warm Status |
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Delivered Variance Beds |
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Undelivered Reserve Status |
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Undelivered Variance Beds |
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License |
Licensed? |
Yes/No |
License Issued Date |
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Licensing Entity |
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License Expired Date |
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License Type |
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Copy of Lease Uploaded? ¨ |
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Licensing POC #1 |
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Licensing POC #1 Email |
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Licensing POC #1 Phone |
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Licensing POC #2 |
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Licensing POC #2 Email |
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Licensing POC #2 Phone |
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Licensing POC #3 |
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Licensing POC #3 Email |
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Licensing POC #3 Phone |
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Grant |
Grant Number |
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Secondary Grant Number |
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Current Grant Project Start Date |
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Current Grant Project End Date |
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Current Grant Budget Start Date |
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Current Grant Budget End Date |
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Initial Grant Award Date |
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Closure Date |
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Initial UC Placement Received Date |
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Closure Date Reason |
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Stop Placement |
Stop Placement (Initial) |
Yes/No |
Anticipated End Date (Initial) |
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Stop Placement Reason (Initial) |
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Start Date (Initial) |
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End Date (Initial) |
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Stop Placement (Transfer) |
Yes/No |
Anticipated End Date (Transfer) |
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Stop Placement Reason (Transfer) |
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Start Date (Transfer) |
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End Date (Transfer) |
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Monitoring Details |
Last Monitoring Date |
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First Admitted Date |
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Due Date for Next Monitoring Visit |
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Number of Sites |
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Monitoring Schedule Notes |
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System Information |
Program Legacy ID |
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Facility Legacy ID |
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RELATED |
Entity Team |
Team Member |
Member Role |
Entity Access Level |
Entry Access Level |
UC Access Level |
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Facility Information |
Title |
Original Document Name |
Record Type |
Document Type |
Description |
Date Received |
Created By |
Created Date |
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Operational Information |
Title |
Original Document Name |
Record Type |
Document Type |
Description |
Date Received |
Created By |
Created Date |
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Compliance Information |
Title |
Original Document Name |
Record Type |
Document Type |
Description |
Date Received |
Created By |
Created Date |
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Entity History |
Date |
Field |
User |
Original Value |
New Value |
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Beds |
Bed Name |
Proposed Delivery Date |
Actual Delivery Date |
Last Modified Date |
Last Update by Alias |
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Funded Capacity Manager |
How many delivered male beds? |
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How many undelivered male beds? |
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How many delivered female beds? |
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How many undelivered female beds? |
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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 |
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Type |
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Country |
List of all countries |
State |
List of all states and the District of Columbia |
ACF Region |
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FFS Region |
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Maximum Months Pregnant |
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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) |
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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.
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Entity Access Level |
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Entry Access Level |
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UC Access Level |
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Record Type/Document Type |
Available Document Types are dependent upon what Record Type is selected.
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File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Herboldsheimer, Shannon (ACF) |
File Modified | 0000-00-00 |
File Created | 2024-07-28 |