Form 1 Standard Shelter Tour Request

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

U.S. Department of Health and Human Services

OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
CARE PROVIDER FACILTY TOUR REQUEST
Please complete Section 1 of this form and submit it to your point of contact within HHS. All requests must be submitted no later
than TWO WEEKS before the requested visit date. Unscheduled visits will not be accommodated.
Times and dates of visits will be confirmed based on shelter availability, taking into account operational and privacy concerns at site
locations. Media is prohibited from accompanying visitors. You will receive notification of the visit approval as soon as it is
processed. Questions regarding your request can be directed to your initial point of contact or [email protected].

SECTION 1 (to be completed by the requester)
A. REQUESTER POINT OF CONTACT
Name:

Organization:

Email:

Phone:

B. REQUESTED DATE AND LOCATION
Date and Time Requested:
Are the date and time requested flexible?

Yes

No

Location Requested (city, region, or specific care provider facility):
Depending on the capacity of the requested location, are you able and willing to visit a different care provider facility to
accommodate your requested visit date?
Yes
No
Purpose of Visit:
C. ADDITIONAL NOTES OR ACCOMADATION REQUESTS

D. REQUESTED VISITORS (add or delete rows as needed)
Name

Title and Organization (include driver’s license number if tour
location is an Influx Care Facility)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is
estimated to average .10/ 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

U.S. Department of Health and Human Services

SECTION 2 (to be completed by ORR)
A. TYPE OF VISITOR
Requires ACF or ORR DCS Headquarters Approval:
Advocates (includes religious groups)
Congressional
Consular Visits (non-standard)

Requires FFS Supervisor or Project Officer Supervisor Approval:
Outside Group Events (religious services, holiday parties, etc.
held by outside groups)

Students

Federal Agencies
International (non-consular)
State/Local Officials
Media
***Please refer any requests from attorneys directly to ORR Division of Policy and do not complete this form***
B. DECISION
Visit Approved?

Yes

No

Special Instructions for Visitors:
Approving Official or Entity:

Date:

C. APPROVED DATE AND LOCATION
Date and Time:
Care Provider Facility Name:
Care Provider Facility Address:
D. ORR POINT OF CONTACT
Name:
Email:
Phone:
E. APPROVED VISITORS (add or delete rows as needed)
Name

Title and Organization (include driver’s license number if tour
location is an Influx Care Facility)

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is
estimated to average .10/ 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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