Form S-14 Long Term Foster Care Travel Request - UC Path Version

Foster Care Travel Request (Form S-14)

UAC Portal Version

OMB# 0970-0553

UAC Basic Information
	(auto populate) First Name:		(auto populate) AKA:
	(auto populate) Last Name:		Status:	(System Generated)
	(auto populate) Date of Birth:		Admitted Date:	(System Generated)
	(auto populate) A#:		Length of Stay:	(System Generated)
	(auto populate) (auto populate) Country of Birth:		Current Program:	(auto populate) (auto populate)
	Sex:		Portal ID:	(Auto populate – Source UAC Portal Discharge Tab)
	Physical Location of the Child:		(auto populate)

Foster Care Travel Request

Requester Information

<Pop-Up Calendar> MM/DD/YYYY Date of Travel Request:	Help Text: (Travel Request form must be submitted to DUACFO at least 5 business days prior to travel start date)
Name and Contact Information of Individual Completing Travel Requests:
Open Text Name:		Open Text Telephone
Open Text Email:

 

Travel Overview

Travel Begin Date:	<Pop-Up Calendar> MM/DD/YYYY	Travel End Date:	<Pop-Up Calendar> MM/DD/YYYY
Name of Individual Adult with whom child will be traveling	Open Text Open Text	Relationship to child:	Open Text Open Text
Contact # while on travel:		Address where child will be staying while on travel
		THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L.104-13) Statement OF PUBLIC BURDEN: The purpose of this information collection is to allow foster care providers to request ORR approval for unaccompanied alien children to travel with their foster family outside of the local community. 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. Act of 1995, unless it displays a currently valid 0MB control number. If you have any comments on this collection of information please contact UACPolicy@acf.hhs.gov.

<Dropdown Menu> - Select a Transportation Mode – Bus; Flight; Personal; Vehicle; Train

Mode of Transportation

Mode of transportation:
Include airline, flight #'s, bus company, train info as applicable:		Open Text

Health Safety Travel Plan

Does the child have any travel-related health concerns or conditions that may impact travel?

c Yes			c No

(Open Text)

If Yes, please explain:

(Open Text)

Please list all medications the child will need during travel, as well as their dosing frequency:

(Open Text)

Describe any additional safety precautions or protocols that should be followed in the event of a health emergency during travel:

Approval Determination

Travel Request Approved by ORR:

c Yes			c No

(Open Text)

If No, please explain:

Open Text

General Comments

Date

System Generated: MM/DD/YYYY

Signature of ORR Official

(Open Text)

Location of Child Appendix

Located on the UAC Portal Discharge Tab

UC Basic Information
	First Name:	(Auto Populate)	AKA:	(Auto Populate)
	Last Name:	(Auto Populate)	Status:	(Auto Populate)
	Date of Birth:	(Auto Populate)	Admitted Date:	(Auto Populate)
	A#:	(Auto Populate)	Length of Stay:	System Generated
	Country of Birth:	(Auto Populate)	Current Program:	(Auto Populate)
	Sex:	(Auto Populate)	Portal ID:	(Auto Populate)
	Physical Location of the Child:		(Auto populate – Source UAC Portal Discharge Tab)

Assessments

{+/-}

Current Location of the Child

Location Type	Name	Address	Last Updated
<Dropdown Menu> (-Select One- Post Release Address Update; Program; Reported Missing Post Release)	AUTOPOPULATE WHEN LOCATION TYPE = “PROGRAM”	AUTOPOPULATE WHEN LOCATION TYPE = “PROGRAM”	AUTOPOPULATE

{+/-}

Location History (AUTOPOPULATE WITH EACH NEW CURRENT LOCATION OF THE CHILD ENTRY)

Location Type	Name	Address	Last Updated
AUTOPOPULATE	AUTOPOPULATE	AUTOPOPULATE	AUTOPOPLATE

>| Print

{+/-}

Transfer Request

>| Add New

{+/-}

Release Request

>| Add New

{+/-}

Discharge Notification

>| Add New

Program Exit

>| Add New

{+/-}

Trigger Reports

CONDITIONAL LOGIC: Additional Fields - Post Release Address Update

Update Current Location of Child

Location Type:

<Dropdown Menu> (SELECTED: Post Release Address Update)

Living with Sponsor?

c Yes c No¹

(CONDITIONAL LOGIC IF “NO”)

Living with a caregiver?

c Yes² c No

(CONDITIONAL LOGIC IF “YES”)
Primary Caregiver Type:	<Dropdown Menu> (-Select Type- Assigned Alternate Caregiver3 /AUTOPOPULATE NAME/; Other Family Member; Family Friend; UAC’s Domestic Partner; Sponsor’s Domestic Partner; Unknown; Other4) (Open Text for” Other”)
Primary Caregiver Name:	(Open Text)	(Open Text)

Address Known?

c Yes⁵ c No

(CONDITIONAL LOGIC IF “YES”)
Search for an Address:	<Search Field> (Open Text)
Current Address Line 1:	(Open Text)
Current Address Line 2:	(Open Text)
City:	(Open Text)
State:	<Dropdown Menu> (-Select One- See Reference Table 1)
Zip Code:	(Open Text)
Country:	<Dropdown Menu> (-Select One- See Reference Table 2)

Notes:

(Open Text)

1 Conditional Logic: Living with Sponsor “No” triggers additional fields

2 Conditional Logic: Living with a Primary Caregiver “Yes” triggers additional fields

3 Conditional Logic: Primary Caregiver Type “Assigned Alternate Caregiver” will auto populate Primary Caregiver Name and Address Fields; address fields are editable if updates required.

4 Conditional Logic: Primary Caregiver Type “Other” triggers additional field

5 Conditional Logic: Address Known “Yes” will trigger additional fields.

S-14 | Version #.#

Valid Through MM/DD/YYYY

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