Form 1 Child Advocate Recommendation and Appointment Form

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services

OFFICE OF REFUGEE RESETTLEMENT
Division of Unaccompanied Children’s Services
The William Wilberforce Trafficking Victims Protection Reauthorization Act of 2008 section 235(c)(6) authorizes the
Secretary of Health and Human Services to appoint “independent child advocates for child trafficking victims and other
vulnerable unaccompanied children.” This appointment authority has been delegated to the Office of Refugee Resettlement
(ORR). ORR will use this form to determine whether a Child Advocate shall be appointed and to document the Child
Advocate’s appointment for UC in ORR/DCS care and custody.
Section 1 (To be completed by the initial referrer)
A. UC information:
Name of UC:
Date of birth:
Language(s) spoken by UC:
Name of referrer:
Relationship of referrer to the UC:

A#:
Nationality:
Current location:
Date of UC’s arrival at care provider:
Date of referral:

B. Checklist (please check all that apply)
Is between the ages of 0-12
Is placed in a residential treatment center or therapeutic facility
Is pregnant or parenting
Has a physical or mental disability
Is a national from a country known to traffic children
Has been identified as a possible child trafficking victim (Interim Assistance Letter, Eligibility Letter, etc.)
Has a criminal or delinquency history and/or is placed in a staff secure care provider or secure care provider, and there are
outstanding issues impacting the UC’s release or discharge plan
Has been a victim of a crime
Is not proficient in a language spoken by staff at the UC’s care provider, and for whom there is no accessible interpreter
routinely available
Will turn 18 in less than six (6) months of placement and for whom family reunification is unlikely
Is identified as being eligible for legal relief
Has a credible fear of returning to their country of origin and/or are seeking voluntary departure despite concerns about
their safety in their home country
Lacks appropriate legal representation, or for whom there is a good faith belief that the child’s legal representative has ties
to child trafficking or criminal activity
Is expected to have a protracted stay of over 120 days in ORR/DCS custody
Whose potential sponsor is undergoing a home study
Is unable to make an independent decision
Any other case where the UC is considered to be exceptionally vulnerable. Explain here:
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is
estimated to average .50/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.

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OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

Section 2 (To be completed by the child advocate program)
A. Does your program recommend that ORR appoint a Child Advocate, and is an individual Child Advocate available
for this UC based on the criteria selected?
Yes.
No. If no, explain here:
More information needed. Explain here:
B. Name of child advocate program official making the recommendation:
(name)

(date)

C. Name of the individual Child Advocate identified for assignment:

Section 3 (To be completed by ORR/DCS)
A. Is the recommendation for the appointment of a Child Advocate approved for the above named UC?:
Yes.
No. If no explain here:
B. Signature of ORR/DCS Division Director:

________________________________ (date)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of
information is estimated to average .50/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.

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