Instructions

Revised 12/10/2009

Form ORR-3 Unaccompanied Refugee Minors Placement

The Unaccompanied Refugee Minor Placement Report, which replaces ICPC-100B (the Interstate Compact on the Placement of Children Initial Placement Form), is an adaptation of that placement report...is to be used for all unaccompanied youth eligible for and provided services through the ORR Unaccompanied Refugee Minor (URM) program.*

*Refer to 45 CFR 400.111 Definition.

When Form is to be Filed

The Unaccompanied Refugee Minor Placement Report is to be used for the following reporting situations:

Initial Placement: Indicate initial placement for newly arrived refugee minors or other eligible youth, and specify if the youth was transferred from the ORR Unaccompanied Alien Children’s (UAC) program. This form is due within 30 days of the initial placement.

Re-entered ORR-funded Services: Placement of youth re-entering URM services is limited to youth who were previously enrolled as a URM and who are eligible to return to the program according to the State’s Title IV-B plan.

Change of Status: Indicate any changes in placement information per the choices available on the form, including youth who emancipate from foster care but are still receiving ORR-funded services. Change in identifying data should include updated information for the youth as well as his/her parents. This form is due within 60 days of the change.

Termination from ORR-Funded Services:** Provide Final Report information related to youth terminating URM services, including the youth’s destination or current situation upon case closure. This form is due within 60 days of case closure.

**Refer to 45 CFR 400.113

Instructions for Completing Form

The following instructions address each section of the report.

Page 1: In the header section at the top of the page, enter the youth’s full name—Family, Middle, Given—and Alien number from the I-94, or, if no Alien number is 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.

SECTION I — REPORT ACTION

Check the appropriate box to indicate whether the report is: Initial Placement (select UAC transfer if child is transferring from any ORR/DUCS-funded placement); Re-entered ORR-funded Services (select foster care or independent living); Change of Status (select all related changes); Termination of ORR-funded Services/Final Report (select the reason for termination of services and provide explanation of the youth’s destination or current situation after terminating services).

SECTION II — IDENTIFYING DATA

1. Sex: Self-explanatory

2. Date of Birth: Include month, day, and year from official document such as immigration documents (I-94, I-360) or birth certificate.

3. Date of Eligibility: Enter the month, day, and year the youth became eligible for services: if refugee, the date arrived in the United States from the I-94 form; if trafficked youth, the date of the ORR eligibility letter; if granted asylum or Special Immigrant Juvenile Status (SIJS), the date on the Immigration Judge’s Order or the I-797/I-171 Notice of Approval of Special Immigrant Petition.

4. Date of Initial Placement: Enter the month, day and year the youth arrived at the URM program and when services commenced.

5. Estimated Date of Emancipation: Enter the estimated month and year the youth is expected to emancipate from the program based upon state’s eligibility policy.

6. a. Country of Origin: Enter the name of the youth's country of citizenship.

b. Ethnic background: Enter the youth’s ethnic group as appropriate.

7. a. Language of origin: Enter youth’s native or first language

b. Other language(s): Enter languages the youth has acquired

8. Eligibility Type: Check the appropriate status.

9. Placement Type: Check the box to identify youth arriving from overseas to enter URM services.

10. National Voluntary Agency: Enter the name of the voluntary resettlement agency which sponsored or assisted in the placement of the youth.

11. Parent of child: Indicate if the youth is a parent and the number of children the youth has while in care (whether at or during placement), followed by names, birthdates and citizenship/immigration status for each child.

12. Mother's Name: Provide the mother’s family, middle and given names, and if living, her last known address at the time the youth arrived in the U.S. Provide current address of mother, if different from above address. Indicate "Yes," "No" or “Unknown” in the blank as to whether or not the mother of the youth is living.

13. Father's Name: Provide the father’s family, middle and given names, and if living, the last known address at the time the youth arrived in the U.S. Provide current address of father, if different from above address. Indicate "Yes," "No" or “Unknown” in the blank as to whether or not the father of the youth is living.

SECTION III – IMMIGRATION STATUS DATA

Current Immigration Status: Indicate the youth’s current immigration status or situation. This may differ from the youth’s eligibility for the URM program. Complete only the current immigration status or lack thereof in the initial placement report. If checking “Other,” fill in the blank with the youth’s immigration status or situation at placement.

New Immigration Status: Indicate the youth’s change in immigration status. This may occur for various reasons, but most frequently it will be an adjustment of status to Legal Permanent Residency or initial immigration status, i.e. T-Visa, Grant of Asylum. Complete this section only if you have indicated you are reporting a change in immigration status in Section I - Report Action. If checking “Other,” fill in the blank with the youth’s changed immigration status or situation.

A change in immigration status may render a child no longer eligible for the URM program. This may be particularly true for Cuban/Haitian Entrants. Consult ORR with questions. U.S. citizens are no longer eligible for the URM program.

SECTION IV – PLACEMENT DATA

1. Placement Type: Check the appropriate box to indicate the type of placement for the youth. Fill in the blank to describe “other” placements.

2. Placement Date: Enter month, day and year of the actual date of this placement action.

3. Placement Cost: Indicate the average daily rate in dollars related to placement type.

4. Foster Parents/Youth’s Relative: Indicate the name, address and phone number of the foster parent/s, or if placed with a relative, state the relationship of the relative to the youth and provide the name, address and phone number of the relative. Leave this field blank if youth has emancipated from foster care and is no longer receiving placement services.

5. Provider Agency for Placement: Indicate the name, address and phone number of the provider agency providing placement services to the youth, if different from the URM provider agency, such as with subcontracted placements.

6. Medical Coverage: Check the appropriate box for medical coverage and provide coverage provision if “Other.”

SECTION V — LEGAL RESPONSIBILITY DATA

1. Court with jurisdiction: Provide the name and address of the court having jurisdiction over the youth and enter the date that the court established legal responsibility (custody, guardianship, conservatorship, etc.). If court jurisdiction has ended for this child, proceed to questions 3 and 4.

2. Agency to whom legal responsibility assigned: Provide the name and address of the agency with legal responsibility for the youth.

3. Has legal responsibility ended? Check the appropriate box to indicate “yes” or “no” and enter the date on which legal responsibility ended.

4. Voluntary Placement Agreement: Check the appropriate box to indicate whether the youth signed a voluntary placement agreement and enter the date the agreement was signed.

SECTION VI — INDEPENDENT LIVING DATA

1. Youth Residence: Indicate the address and phone number of the youth who has emancipated from foster care and is no longer provided “placement” services. Leave this field blank if the youth is receiving independent living services and remains in a foster care placement.

2. Service Type: Check the appropriate box(es) to indicate the Educational benefits (Ed) or Independent Living (IL) services the youth is receiving and select a corresponding funding source.

3. For all listed ORR-funded services, list provider: Indicate by service the name and contact information of the agency providing Independent Living services to the youth.

SECTION VII — FORM SUBMISSION AUTHORITY

1. 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.

2 State Agency: Provide the name, address and phone number of the state agency, the signature of the state official submitting the report, and the date of the signature.

DISTRIBUTION OF REPORT:

The appropriate state agency representative should send the Form ORR-3 to:

1) Office of Refugee Resettlement via 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 one-quarter hour 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.

5 of 5