Today M-D-Y
The information collected in this survey is very important in ensuring that the new arrival(s) receive appropriate services. Please fill it out as completely as you can. For more information on the questions asked in this survey and instructions on how to fill out the survey, please open the PDF below.
Who is submitting this arrival notification?
* must provide value
Resettlement Agency Sponsor / Sponsorship Circle Local Public Health Community-based Organization Other
What type of organization are you?
* must provide value
What resettlement agency?
* must provide value
Arrive Ministries Minnesota Council of Churches International Institute of Minnesota Lutheran Social Services Lutheran Social Services - St. Cloud Catholic Charities of Southern Minnesota
Submitters first and last name
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Name of person completing this form.
What is ______ 's phone number?
* must provide value
What is ______ 's email?
* must provide value
Does this family have a case manager?
* must provide value
Yes
No
Case manager's first and last name
What is ______ 's phone number?
Is this a free case? (free case means no family ties)
* must provide value
Yes
No
Visa status of new arrivals
* must provide value
Primary Refugee Parolee Asylee (U.S.-granted) SIV Victim of Trafficking Secondary Refugee Secondary Parolee Secondary SIV Secondary Asylee (U.S.-granted) Secondary Asylee (derivative) Secondary Victim of Trafficking
Did this family arrive as part of the Uniting For Ukraine program?
* must provide value
Yes
No
I don't know
Yes
No
Format: HB-111111
Today M-D-Y
Date of arrival to Minnesota
Today M-D-Y
Primary State of Resettlement
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AK AL AR AZ CA CO CT DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY Outside the US
Today M-D-Y
Country of Birth
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AFGHANISTAN ALBANIA ALGERIA ANDORRA ANGOLA ANGUILLA ANTARCTICA ANTIGUA AND BARBUDA ARGENTINA ARMENIA ARUBA ASHMORE AND CARTIER ISLANDS AUSTRALIA AUSTRIA AZERBAIJAN BAHAMAS THE BAHRAIN BAKER ISLAND BANGLADESH BARBADOS BASSAS DA INDIA BELARUS BELGIUM BELIZE BENIN BERMUDA BHUTAN BOLIVIA BOSNIA AND HERCEGOVINA BOTSWANA BOUVET ISLAND BRAZIL BRITISH INDIAN OCEAN TERRITORIES BRITISH VIRGIN ISLANDS BRUNEI BULGARIA BURKINA FASO BURMA BURUNDI CAMBODIA CAMEROON CANADA CAPE VERDE CAYMAN ISLANDS CENTRAL AFRICAN REPUBLIC CHAD CHILE CHINA CHRISTMAS ISLAND CLIPPERTON ISLAND COCOS (KEELING) ISLANDS COLOMBIA COMOROS CONGO CONGO DEMOCRATIC REPUBLIC COOK ISLANDS CORAL SEA ISLANDS COSTA RICA CROATIA CUBA CYPRUS CZECHOSLOVAKIA CZECH REPUBLIC DENMARK DJIBOUTI DOMINICA DOMINICAN REPUBLIC ECUADOR EGYPT EL SALVADOR EQUATORIAL GUINEA ERITREA ESTONIA ETHIOPIA EUROPA ISLAND FALKLAND ISLANDS (ISLAS MALVINAS) FAROE ISLANDS FIJI FINLAND FRANCE FRENCH GUIANA FRENCH POLYNESIA FRENCH SOUTHERN & ANTARCTIC LANDS GABON GAMBIA THE GAZA STRIP GEORGIA GERMANY GHANA GIBRALTAR GLORIOSO ISLANDS GREECE GREENLAND GRENADA GUADELOUPE GUAM GUATEMALA GUERNSEY GUINEA GUINEA-BISSAU GUYANA HAITI HEARD ISLAND & MCDONALD ISLANDS HONDURAS HONG KONG HOWLAND ISLAND HUNGARY ICELAND INDIA INDONESIA IRAN IRAQ IRAQ-S ARABIA NEUTRAL ZONE IRELAND ISLE OF MAN ISRAEL ITALY IVORY COAST JAMAICA JAN MAYEN JAPAN JARVIS ISLAND JERSEY JOHNSTON ATOLL JORDAN JUAN DE NOVA ISLAND KAZAKHSTAN KENYA KINGMAN REEF KIRIBATI KOREA NORTH (DEMOCRATIC PEOPLES REP) KOREA SOUTH (REPUBLIC OF) KOSOVO KURDS KUWAIT KYRGYZSTAN LAOS/HMONG LAOS/OTHER LATVIA LEBANON LESOTHO LIBERIA LIBYA LIECHTENSTEIN LITHUANIA LUXEMBOURG MACAU MACEDONIA MADAGASCAR MALAWI MALAYSIA MALDIVES MALI MALTA MARSHALL ISLANDS MARTINIQUE MAURITANIA MAURITIUS MAYOTTE MEXICO MICRONESIA FEDERATED STATES OF MIDWAY ISLAND MOLDOVA MONACO MONGOLIA MONTENEGRO MONTSERRAT MOROCCO MOZAMBIQUE NAMIBIA NAURU NAVASSA ISLAND NEPAL NETHERLANDS NETHERLANDS ANTILLES NEW CALEDONIA NEW ZEALAND NICARAGUA NIGER NIGERIA NIUE NORFOLK ISLAND NORTHERN MARIANA ISLAND NORWAY NOT SPECIFIED OMAN OTHER PAKISTAN PALMYRA ATOLL PANAMA PAPUA NEW GUINEA PARACEL ISLANDS PARAGUAY PERU PHILIPPINES PITCAIRN ISLANDS POLAND PORTUGAL PUERTO RICO QATAR REUNION ROMANIA RUSSIA RWANDA SAINT GEORGIS AND THE SOUTH SANDWICH ISLANDS SAINT HELENA SAINT KITTS AND NEVIS SAINT LUCIA SAINT PIERRE AND MIQUELON SAINT VINCENT AND THE GRENADINES SAMOA SAN MARINO SAO TOME AND PRINCIPE SAUDI ARABIA SENEGAL SERBIA SEYCHELLES SIERRA LEONE SINGAPORE SLOVAKIA SLOVENIA SOLOMON ISLANDS SOMALIA SOUTH AFRICA SOUTH SUDAN REPUBLIC OF SPAIN SPRATLY ISLANDS SRI LANKA SUDAN SURINAME SVALBARD SWAZILAND SWEDEN SWITZERLAND SYRIA TAIWAN TAJIKISTAN TANZANIA UNITED REPUBLIC OF THAILAND TIBET TIMOR-LESTE TOGO TOKELAU TONGA TRINIDAD AND TOBAGO TROMELIN ISLAND TRUST TERRITORIES OF PACIFIC TUNISIA TURKEY TURKMENISTAN TURKS AND CAICOS ISLANDS TUVALU UGANDA UKRAINE UNITED ARAB EMIRATES UNITED KINGDOM UNITED STATES UNKNOWN URUGUAY U.S. MINOR OUTLYING ISLANDS US MISC PACIFIC ISLANDS UZBEKISTAN VANUATU (NEW HEBRIDES) VATICAN CITY VENEZUELA VIETNAM VIRGIN ISLANDS WAKE ISLAND WALLIS AND FUTUNA WEST BANK WESTERN SAHARA WESTERN SAMOA YEMEN YUGOSLAVIA ZAMBIA ZIMBABWE
This letter has more health information for sponsors. We recommend emailing or sending this letter to the family or sponsor you are working with since it includes many live links. The letter below can be emailed :
The letter below can be printed:
First name of principal applicant/head of household
* must provide value
______ 's last name
* must provide value
______ ______ 's date of birth
* must provide value
Today M-D-Y
______ ______ 's sex:
* must provide value
Female
Male
______ ______ 's Alien number:
This is NOT a required field
How many total family members?
* must provide value
Number of people on assurance form
County
* must provide value
Aitkin Anoka Becker Beltrami Benton Big Stone Blue Earth Brown Carlton Carver Cass Chippewa Chisago Clay Clearwater Cook Cottonwood Crow Wing Dakota Dodge Douglas Faribault Fillmore Freeborn Goodhue Grant Hennepin Houston Hubbard Isanti Itasca Jackson Kanabec Kandiyohi Kittson Koochiching Lac Qui Parle Lake Lake of the Woods Le Sueur Lincoln Lyon Mahnomen Marshall Martin McLeod Meeker Mille Lacs Morrison Mower Murray Nicollet Nobles Norman Olmsted Otter Tail Pennington Pine Pipestone Polk Pope Ramsey Red Lake Redwood Renville Rice Rock Roseau St. Louis Scott Sherburne Sibley Stearns Steele Stevens Swift Todd Traverse Wabasha Wadena Waseca Washington Watonwan Wilkin Winona Wright Yellow Medicine Out of State
Hennepin County Contact Information
Omar Hassan
FAX: 612-596-7900
OFFICE: 612-543-3109 #
EMAIL: omar.hassan@hennepin.us
Rice County Contact Information
Marie McCarthy
FAX: 507-332-5932
OFFICE: 507-332-5928 #
EMAIL: mmccarthy@co.rice.mn.us
Kandiyohi County Contact Information
Carmen MacLennan
FAX: 320-231-7888
OFFICE: 320-231-7800 x 2562
EMAIL: carmen.maclennan@kcmn.us
Please copy and paste the email of your county contact shown above in the text box below so we can notify them of this new arrival.
* must provide value
Does anyone in the arriving family have a medical condition that needs a doctor? This includes pregnancy, diseases such as high blood pressure or diabetes, or anyone on medication.
Yes
No
Please list who in the family has medical conditions.
Format: (Name, A number)
Format: Name, XXX-XXX-XXX; Name, XXX-XXX-XXX; etc.
Does this family need an interpreter?
* must provide value
Yes
No
Does this family need transportation?
* must provide value
Yes
No
What language?
* must provide value
Has this family already been connected to health care (scheduled with or already seen a medical provider)?
* must provide value
Yes
No
What clinic have they been seen at?
* must provide value
Is there a clinic/health system near you where they could be seen at?
It's fine to leave this field blank.
Does this family have MA/insurance?
* must provide value
Yes
No
Has the family submitted and MA application?
* must provide value
Yes
No
I don't know
Please submit the MA numbers for each family member who recently arrived to Minnesota (Last Name, First Name, MA number). If any family member does not have an MA number, list "Unknown".
* must provide value
Today M-D-Y
Do you have a family assurance form that lists out all the individuals in the family?
Yes
No
Please attach the family assurance form
Collecting Alien numbers (A#) are extremely important to our program activities because it helps us ensure we are providing the best care. Please report that information if you have access to it. It is typically found on travel authorization documents like the one shown below.
Please list out all the individuals of the family who recently arrived to Minnesota (Last Name, First Name, Middle, Sex, Date of Birth, A#, Country of Birth)
* must provide value
Please attach any relevant biodata, SMC forms, I94, or other immigration documentation:
Sent to Hennepin for Igra help?
Yes
No
Yes
No
Ineligible