Form ORR-4
Revised 2010
ORR-4 Unaccompanied Refugee Minors Outcomes
When Form is to be Filed
The Unaccompanied Refugee Minor (URM) Outcomes Report is required for each individual youth enrolled in the program, to be submitted annually beginning approximately 12 months from the initial date of the youth’s placement and every 12 months thereafter. This report provides information on the status and personal functioning of the youth and assists the Office of Refugee Resettlement (ORR) to assess the youth’s progress and to meet reporting requirements in the Immigration and Nationality Act (8 U.S.C. 1522, Section 412(d)). Failure to provide these reports may result in delay, suspension, or termination of grant support.
Sections IV and V of Form ORR-4 assist ORR to gather information on service provision and outcomes for URMs similar to the information gathered for other foster children via the National Youth in Transition Database (NYTD). This information will assist ORR in understanding program effectiveness, as well as broader planning for the URM program.
All sections of the form are to be completed annually for youth that are 17 through 21 years old; all other form sections except IV and V must be completed for youth who have not yet turned 17 years old.
In addition, Sections I, V, and VI only of Form ORR-4 should be completed within 30 days of placement into the URM program of a youth who is 17 years old, in conjunction with or following an initial ORR-3 placement report, in order to achieve a baseline of information.
Additionally, these sections must be completed regardless of whether the youth is in foster care, and are designed to collect information on a follow-up basis, including for youth who have left URM foster care and are no longer receiving URM-funded independent living services. Such youth may be receiving independent living services and benefits from a State title IV-B/IV-E agency rather than through URM funding, or may have chosen to terminate all services. Effort should be made to locate and obtain information from such former URM clients through the age of 21; if it is not possible to locate a former URM or the former URM declines to participate, these circumstances should be reported.
Finally, the Form ORR-4, including Sections IV and V, should be completed annually for any youth who is over the age of 21 and continues to receive an ORR-funded independent living benefit or service, such as the equivalent of an education and training voucher, in keeping with the State’s title IV-B or IV-E Plan.
Instructions for Completing Form
A case worker or another individual involved in providing direct services to the child shall complete this form. The State agency shall review, sign and forward the form as described below.
The following instructions address each section of the report.
Page 1: At the top of the page, enter the youth’s full name—Family, Middle, Given—and Alien number from the I-94, or, if the Alien number is not available, enter the HHS Tracking number for youth issued an eligibility letter by ORR as a victim of a severe form of human trafficking. This information becomes the header for subsequent report pages.
State Agency: Enter the name, address and contact information for the State Agency submitting the report.
Initial Checkboxes
Check the appropriate box to indicate that this report is submitted: standard annual outcomes report for youth 17 to 21 years old who are receiving services; report for a youth over the age of 21 who continues to receive ORR-funded independent living services and benefits in keeping with the State title IV-B or IV-E plan; follow-up annual outcomes report for youth age 17 to 21 years who are no longer receiving services; or report comprising only Sections I, V and VI for a 17-year-old youth within 30 days of initial placement into the URM program, and in conjunction with or following an ORR-3 placement report.
SECTION I — IDENTIFYING DATA
Date of Birth: Include month, day, and year from official document such as immigration documents (such as an I-94) or birth certificate. This data element is required on each annual report to update or correct the birth date.
National Voluntary Agency: Enter the name of the voluntary resettlement agency which assisted in the placement of the youth.
URM Provider: Provide the name, address, phone number and email address of the URM provider agency.
SECTION II — PERSONAL FUNCTIONING OF THE YOUTH
Educational Information
Current school grade level: Provide the youth's school grade level in the available space. If the youth is not currently in school, give most recent grade level.
Current school level: Check the appropriate box and provide additional curricular information, as appropriate, in the space provided.
Check the appropriate box to indicate if the youth required and received educational remedial services, defined as additional educational services, including special testing, tutorial, bilingual or translation services, etc. Check the appropriate box. If the response is yes, specify the services received by the youth during this reporting period.
Educational or vocational skills, certificates or diplomas: Check the appropriate box indicating “yes” or “no.” This question is to be completed for youth age 16 and below; Section V will capture this information for youth 17 and older. If the response is “yes,” provide specific educational accomplishments achieved during this reporting period.
Caseworker/Provider Assessment: Provide best assessment of the youth to date as “Adequate” or “Not Adequate,” where adequate is defined as functioning at an age-appropriate level, by checking the appropriate box for four function areas: English Language Skill; Education--other than English language; Social Adjustment; and Health Condition. If selecting “Not Adequate,” enter in the space provided a specific explanation of impediments to progressive development and actions detailed in the youth's plan to improve in these areas.
SECTION III — FAMILY REUNIFICATION DATA
Describe efforts in the reporting period to reunify a youth with his or her parents or other relatives. Provide the date of the most recent permanency plan review, and discuss updates in information regarding potential caregiver relatives in the U.S. and abroad. Include any, even partial, family reunification information such as names, addresses, phone numbers, etc. Explain any decisions made in the reporting period not to reunify a youth under the age of 18 with a relative. If this is the initial outcomes report and family reunification activity has not occurred, please indicate so.
Refer to ORR policy guidance in ORR’s Statement of Goals, Priorities, Standards, and Guidelines for the Unaccompanied Minor Refugee and Cuban/Haitian Entrant Programs regarding reunification with parents (see section III. Program Standards, Legal Considerations, B. Family Reunion).
Section IV – INDEPENDENT LIVING SERVICES
Questions in this section may be completed by an individual providing direct service to the youth. Check the numbered box related to services received during the reporting period for all elements in this section, with the exception of element # 3 on educational level, where the response should indicate the highest educational level achieved by the youth during the reporting period. Also indicate the payment source (ORR, State/Chafee, or private) for elements 5 through 18 of this section.
Provide the residential address for youth no longer in foster care but continuing in ORR-funded educational or independent living services, or for youth who have terminated services but are 17-21 years old and in the follow-up outcomes reporting period. Leave this field blank if youth remains in foster care.
Following are definitions of services available on the Form ORR-4:
a. Foster care status—services. The youth receiving services is in foster care under the placement and care responsibility of the State, county or URM provider agency in a 24-hour substitute care placement on the date of outcomes data collection. Placement includes but is not limited to foster family homes, foster homes of relatives, group homes, emergency shelters, residential facilities, and child care institutions. Indicate whether the youth is or was in foster care at any point during the last 12 months.
i. Adjudicated delinquent. A State or Federal court of competent jurisdiction has adjudicated the youth as a delinquent.
ii. Educational level. The highest educational level completed by the youth. For example, for a youth currently in 11th grade, ‘‘10th grade’’ is the highest educational level completed. Postsecondary education or training refers to any post-secondary education or training, other than an education pursued at a college or university. College refers to completing at least a semester of study at a college or university.
iii. Special education. Specifically designed instruction, at no cost to parents, to meet the unique needs of a child with a disability.
iv. Independent living needs assessment. A systematic procedure to identify a youth’s basic skills, emotional and social capabilities, strengths, and needs to match the youth with appropriate independent living services. An independent living needs assessment may address knowledge of basic living skills, job readiness, money management abilities, decision-making skills, goal setting, task completion, and transitional living needs.
v. Academic support. Services designed to help a youth complete high school or obtain a General Equivalency Degree (GED). Such services include: academic counseling; preparation for a GED, including assistance in applying for or studying for a GED exam; tutoring; help with homework; study skills training; literacy training; and help accessing educational resources. Academic support does not include a youth’s general attendance in high school.
vi. Post-secondary educational support. Services designed to help a youth enter or complete a postsecondary education and include: classes for test preparation, such as the Scholastic Aptitude Test (SAT); counseling about college; information about financial aid and scholarships; help completing college or loan applications; or tutoring while in college.
vii. Career preparation. Services that focus on developing a youth’s ability to find, apply for, and retain appropriate employment including: vocational and career assessment (career exploration and planning, guidance in setting and assessing vocational and career interests and skills, and help in matching interests and abilities with vocational goals); job seeking and job placement support (identifying potential employers, writing resumes, completing job applications, developing interview skills, job shadowing, receiving job referrals, using career resource libraries, understanding employee benefits coverage, and securing work permits); retention support, e.g., job coaching; learning how to work with employers and other employees; understanding workplace values such as timeliness and appearance; and understanding authority and customer relationships.
viii. Employment programs or vocational training. Designed to build a youth’s skills for a specific trade, vocation, or career through classes or on-site training. Employment programs include an apprenticeship, internship, or summer employment program and do not include summer or after-school jobs secured by the youth alone. Vocational training includes a youth’s participation in vocational or trade programs and the receipt of training in occupational classes for such skills as cosmetology, auto mechanics, building trades, nursing, computer science, and other current or emerging employment sectors.
ix. Budget and financial management. Assistance includes the following types of training and practice: living within a budget; opening and using a checking and savings account; balancing a checkbook; developing consumer awareness and smart shopping skills; accessing information about credit, loans and taxes; and filling out tax forms.
x. Housing education and home management training. Assistance or training in locating and maintaining housing (filling out a rental application and acquiring a lease, handling security deposits and utilities, understanding practices for keeping a healthy and safe home, understanding tenants’ rights and responsibilities, and handling landlord complaints). Home management includes instruction in food preparation, laundry, housekeeping, living cooperatively, meal planning, grocery shopping and basic maintenance and repairs.
xi. Health education and risk prevention. Providing information about: hygiene, nutrition, fitness and exercise, and first aid; medical and dental care benefits, health care resources and insurance, prenatal care and maintaining personal medical records; sex education, abstinence education, and HIV prevention (education and information about sexual development and sexuality, pregnancy prevention and family planning, and sexually transmitted diseases and AIDS); substance abuse prevention and intervention (education and information about the effects and consequences of substance use--alcohol, drugs, tobacco--and substance avoidance and intervention). Health education and risk prevention does not include the youth’s actual receipt of direct medical care or substance abuse treatment.
xii. Family support and healthy marriage education. Such services include education and information about safe and stable families, healthy marriages, spousal communication, parenting, responsible fatherhood, childcare skills, teen parenting, and domestic and family violence prevention.
xiii. Mentoring. The youth has been matched with a screened and trained adult for a one-on-one relationship that involves the two meeting on a regular basis. Mentoring can be short-term, but it may also support the development of a long-term relationship. While youth often are connected to adult role models through school, work, or family, this service category only includes a mentor relationship that has been facilitated, paid for or provided by the State agency or its staff.
xiv. Supervised independent living. The youth is living independently under a supervised arrangement that is paid for or provided by the State agency. A youth in supervised independent living is not supervised 24 hours a day by an adult and often is provided with increased responsibilities, such as paying bills, assuming leases, and working with a landlord, while under the supervision of an adult.
xv. Room and board financial assistance. Payment that is paid for or provided by the State agency for room and board, including rent deposits, utilities, and other household start-up expenses.
xvi. Education financial assistance. Payment that is paid for or provided by the State agency for education or training, including allowances to purchase textbooks, uniforms, computers, and other educational supplies; tuition assistance; scholarships; payment for educational preparation and support services (i.e., tutoring), and payment for GED and other educational tests. This financial assistance also includes vouchers for tuition or vocational education or tuition waiver programs paid for or provided by the State agency.
xvii. Other financial assistance. Any other payments made or provided by the State agency to help the youth live independently.
b. Provide agency information for any ORR-funded service indicated in #5-18.
Section V – Independent Living Outcomes
This section must be completed as a result of surveying the youth (URM or former URM) using survey questions from the NYTD which correspond to questions 4 – 25 in this section. Following are definitions of outcomes to be reported in the Form ORR-4:
1. Outcomes reporting status. Represents the youth’s participation, or lack thereof, in the outcomes data collection. If information is collected via survey of the youth on any of the data elements in 4 – 25 of this section, indicate that the youth participated. If unable to to collect the information by surveying the youth, indicate the reason and leave the data elements in 4 – 25 of this section blank.
a. Youth participated. The youth participated in the outcome survey, either fully or partially.
b. Youth declined. The youth was successfully located and his or her participation was invited, but the youth declined to participate in the data collection.
c. Incapacitated. The youth has a permanent or temporary mental or physical condition that prevents him or her from participating in the outcomes data collection.
d. Incarcerated. The youth is unable to participate in the outcomes data collection because of his or her incarceration.
e. Runaway/missing. A youth in foster care is known to have run away or be missing from his or her foster care placement.
f. Unable to locate/invite. The State agency could not locate a youth who is not in foster care or otherwise invite such a youth’s participation.
g. Death. The youth died prior to his participation in the outcomes data collection.
2. Date of outcome data collection. The latest date that data was collected from a youth for the elements described in 4 – 25 of this section. Indicate the month, day and year of the outcomes data collection.
3. Foster care status—outcomes. Indicate if the youth is in foster care under the placement and care responsibility of the State, county or URM provider agency in a 24-hour substitute care placement on the date of outcomes data collection. This includes but is not limited to placement in foster family homes, foster homes of relatives, group homes, emergency shelters, residential facilities, and child care institutions. Indicate whether the youth is in foster care with a ‘‘yes’’ or ‘‘no’’ as appropriate.
For data elements 4 - 25, indicate whether the following outcomes apply with a ‘‘yes’’ or ‘‘no’’ as appropriate, based on the youth’s response. If the youth does not answer a question, indicate ‘‘declined.’’ An exception is data element 13, where options are provided to indicate the highest educational certification received.
For data elements 9 - 11 of this section, indicate “not applicable” if the youth remains in foster care.
For data element 20 of this section, indicate “not applicable” if the answer to 19 is “no.”
Data elements 21-25 include a “don’t know” option, and 22-25 include a “not applicable” option.
4. Current full-time employment. A youth is employed full-time if employed at least 35 hours per week in one or multiple jobs as of the date of the outcome data collection.
5. Current part-time employment. A youth is employed part-time if employed between one and 34 hours per week in one or multiple jobs as of the date of the outcome data collection.
6. Employment-related skills. A youth has obtained employment-related skills if the youth completed an apprenticeship, internship, or other on-the-job training, either paid or unpaid, in the past year. The experience must help the youth acquire employment-related skills, e.g., specific trade skills such as carpentry or auto mechanics, or office skills such as word processing or use of office equipment.
7. Social Security. A youth is receiving some form of Social Security if receiving Supplemental Security Income (SSI) or Social Security Disability Insurance (SSDI), either directly or as a dependent beneficiary as of the date of the outcome data collection. SSI payments are made to eligible low-income persons with disabilities. SSDI payments are made to persons with a certain amount of work history who become disabled. A youth may receive SSDI payments through a parent, although this would be an unusual occurrence for a URM or former URM.
8. Educational aid. A youth is receiving educational aid if using a scholarship, voucher (including education or training vouchers pursuant to section 477(h)(2) of the Social Security Act), grant, stipend, student loan, or other type of educational financial aid to cover educational expenses as of the date of the outcome data collection. Scholarships, grants, and stipends are funds awarded for spending on expenses related to gaining an education. ‘‘Student loan’’ means a government-guaranteed, low-interest loan for students in post-secondary education.
9. Public financial assistance. A youth is receiving public financial assistance if receiving ongoing cash welfare payments from the government to cover some of his or her basic needs, as of the date of the outcome data collection. Public financial assistance does not include government payments or subsidies for specific purposes, such as unemployment insurance, child care subsidies, education assistance, food stamps or housing assistance.
10. Public food assistance. A youth is receiving public food assistance if receiving food stamps in any form (i.e., government-sponsored checks, coupons or debit cards) to buy eligible food at authorized stores as of the date of the outcome data collection. This definition includes receiving public food assistance through the Women, Infants, and Children (WIC) program.
11. Public housing assistance. A youth is receiving public housing assistance if the youth is living in government-funded public housing, or receiving a government-funded housing voucher to pay for part of his/her housing costs as of the date of the outcome data collection. CFCIP room and board payments are not included in this definition.
12. Other financial support. A youth has other financial support if receiving any other periodic and/or significant financial resources or support from another source not listed in the elements described in elements 8 -11 of this section as of the date of outcome data collection. Such support can include payments from a spouse or family member (biological, foster or adoptive), child support that the youth receives for him or herself, or funds from a legal settlement. This definition does not include occasional gifts, such as birthday or graduation checks or small donations of food or personal incidentals, child care subsidies, child support for a youth’s child, or other financial support which does not benefit the youth directly in supporting himself or herself.
13. Highest educational certification received. A youth has received an education certificate if the youth has a high school diploma or general equivalency degree (GED), vocational certificate, vocational license, associate’s degree (e.g., A.A.), bachelor’s degree (e.g., B.A. or B.S.), or a higher degree as of the date of the outcome data collection. Indicate the highest degree that the youth has received.
a. A vocational certificate is a document stating that a person has received education or training that qualifies him or her for a particular job, e.g., auto mechanics or cosmetology.
b. A vocational license is a document that indicates that the State or local government recognizes an individual as a qualified professional in a particular trade or business.
c. An associate’s degree is generally a two-year degree from a community college.
d. A bachelor’s degree is a four-year degree from a college or university.
e. A higher degree indicates a graduate degree, such as a Master’s Degree or a Juris Doctor (J.D.).
f. None of the above means that the youth has not received any of the above educational certifications.
14. Current enrollment and attendance. Indicate whether the youth is enrolled in and attending high school, GED classes, or postsecondary vocational training or college, as of the date of the outcome data collection. A youth is still considered enrolled in and attending school if the youth would otherwise be enrolled in and attending a school that is currently out of session.
15. Connection to adult. A youth has a connection to an adult if, as of the date of the outcome data collection, the youth knows an adult who he or she can go to for advice or guidance when there is a decision to make or a problem to solve, or for companionship when celebrating personal achievements. The adult must be easily accessible to the youth either by telephone or in person. This can include but is not limited to adult relatives, parents or foster parents. The definition excludes spouses, partners, boyfriends or girlfriends and current caseworkers.
16. Homelessness. A youth is considered to have experienced homelessness if the youth had no regular or adequate place to live. For a 17-year-old youth, the data element relates to a youth’s lifetime experiences. Many URMs have lifetime experiences of having no regular or adequate place to live for at least a portion of their lives, but may not have experienced the NYTD definition of situations where the youth has lived in a car or on the street, or staying in a homeless or other temporary shelter. The youth’s perception of whether their lifetime experience includes a period of no regular or adequate place to live determines whether the answer to this element is “yes” or “no.” For a youth 18 years or older, the data element relates to the youth’s experience in the past year.
17. Substance abuse referral. A youth has received a substance abuse referral if the youth was referred for an alcohol or drug abuse assessment or counseling. For a 17-year-old youth, the data element relates to a youth’s lifetime experience. For a youth 18 years or older, the data element relates to the youth’s experience in the past year. This definition includes either a self-referral or referral by a social worker, school staff, physician, mental health worker, foster parent, or other adult. Alcohol or drug abuse assessment is a process designed to determine if someone has a problem with alcohol or drug use.
18. Incarceration. A youth is considered to have been incarcerated if the youth was confined in a jail, prison, correctional facility, or juvenile or community detention facility in connection with allegedly committing a crime (misdemeanor or felony). For a 17-year-old youth, the data element relates to a youth’s lifetime experience. For a youth 18 years or older, the data element relates to the youth’s experience in the past year.
19. Children. A youth is considered to have a child if the youth has given birth herself, or the youth has fathered any children who were born. For a 17- year-old youth in the baseline population, the data element relates to a youth’s lifetime experience. For a youth 18 years or older, the data element relates to the youth’s experience in the past year. This refers to biological parenthood.
20. Marriage at child’s birth. A youth is married at the time of the child’s birth if he or she was united in matrimony according to the laws of the State to the child’s other parent. Indicate whether the youth was married to the child’s other parent at the time of the birth of any child reported in the element described in 19 of this section. This does not include common law marriages or customary marriages which did not result in documentation of the marriage recognized by the State or country of residence at the time of the marriage.
21. Medicaid. A youth is receiving Medicaid if the youth is participating in a Medicaid-funded State program, which is a medical assistance program supported by the Federal and State government under title XIX of the Social Security Act as of the date of outcomes data collection.
22. Other health insurance coverage. A youth has other health insurance if the youth has a third-party pay (other than Medicaid) for all or part of the costs of medical care, mental health care, and/or prescription drugs, as of the date of the outcomes data collection. This definition includes group coverage offered by employers, schools or associations, an individual health plan, self-employed plans, or inclusion in a parent’s insurance plan. This also could include access to free health care through a college, Indian Health Service, or other source. Medical or drug discount cards or plans are not insurance.
23. Health insurance type: Medical. If the youth has indicated that he or she has health insurance coverage in the element described in 22 of this section, indicate whether the youth has insurance that pays for all or part of medical health care services.
24. Health insurance type: Mental health. If the youth has indicated that he or she has medical health insurance coverage as described in 23 of this section, indicate whether the youth has insurance that pays for all or part of the costs for mental health care services, such as counseling or therapy.
25. Health insurance type: Prescription drugs. If the youth has indicated that he or she has medical health insurance coverage as described in 23 of this section, indicate whether the youth has insurance coverage that pays for part or all of the costs of some prescription drugs.
26. Health insurance type: Other. If the youth has indicated that he or she has medical health insurance coverage as described in 23 of this section, indicate whether the youth has insurance coverage that pays for part or all of the costs of other medical services, e.g., dental or vision. Enter the other type of coverage in the blank provided.
SECTION VI — FORM SUBMISSION AUTHORITY
Unaccompanied Refugee Minor (URM) Provider Agency: Provide the name, address and phone number of the URM provider agency, the signature of the person preparing the report including the signatory’s name and title and the date of the signature.
Supervising State Agency: Provide the name, address and phone number of the supervising state agency, the signature of the state official submitting the report, and the date of the signature.
Distribution of Report Copies
The appropriate state agency representative should send the Form ORR-4 to:
1) Office of Refugee Resettlement via the ACF electronic URM mailbox with a PDF version of the signature page attached.
2) National Voluntary Agency; and
3) URM Provider Agency.
"THE PAPERWORK REDUCTION ACT OF 1995"
Public reporting burden for this collection of information is estimated to average 1.25 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.
| File Type | application/msword |
| File Title | ORR-4 Refugee Unaccompanied Minors Progress |
| Author | Constance Combs |
| Last Modified By | Constance Combs |
| File Modified | 2009-12-24 |
| File Created | 2009-12-24 |