ORR-3 Report Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0970-XXXX

Office of Refugee Resettlement

Exp. XX/XX/XXXX

Name of Youth

Alien Registration No.

HHS Tracking No.

Last

First

Middle

ORR-3 REPORT FORM

UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM

PLACEMENT REPORT

State Agency

URM Provider Agency

Agency Name:

Agency Name:

Address:

Address:

City:

City:

State:

Zip:

State:

Zip:

National Voluntary Agency

USCCB

LIRS

Not Applicable

Section I: Report Action

1. Initial Placement - Must be submitted within 30 days of placement

2. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change

Date of Action (mm/dd/yyyy)

Establishing/changing legal responsibility

Transfer to/from another URM Program**

Change in placement type and address

Change in placement cost

Change in immigration/eligibility data

Change in biological parent's location

Absent from program but legal custody retained

Emancipated from placement services but receiving ORR-funded IL/education services

Became a parent

Change in identifying data,e.g., age redetermination, name, received A#,

or development of a safety plan.

**

Please note which State Provider youth is transferring to/from in the explanation box below

Explain "Change of Status" if necessary

3. Termination of ORR-funded services/Final Report:

Date of Termination:

Reunified with Parents:

Dismissed from Program

within the US

Ran Away

Overseas

Departure from US:

Removal

Relative (Granted Legal Responsibility)

Voluntary Departure

Non-relative (Granted Legal Responsibility)

Loss of Eligibility

Emancipation

Immigration Detention

with state / Chafee-funded IL / Education services

Incarcerated

Conclusion of ORR-funded IL / Education services

Deceased

Voluntary Termination

Other

Explain destination/current situation at case closure.

4. Re-entered ORR-funded placement and/or services

Date of Re-entry (mm/dd/yyyy)

URM Placement

Independent Living Services

Section II: Identifying/ Basic Data

1. Sex:

2. Date of Birth

3. Date of Eligibility

4. Date of Initial Placement

Female

Male

5a. Est. Emancipation from Placement

5b. Est. Date of Termination from ORR-funded IL / Edu. Services

6a. Country of Origin:

6b. Ethnic Group:

7a. Language of Origin:

7b. Other Language(s):

8. Eligibility Type:

Refugee

Asylee

Entrant

U Status Recipient

Trafficking Victim

Special Immigrant Juvenile (SIJ)

Other:

9. Has a safety plan been developed?

Yes

No

Not applicable

10. URM's Children in Care:

First Name, Second Name, Last Name

DOB

Citizenship / Immigration Status

1st child

2nd child

3rd child

11. Mother of URM:

Last:

First:

Middle:

a. Living:

b. Mother's address when minor arrived in U.S.:

Yes

No

c. Current Address:

Unknown

Same as b. above

12. Father of URM:

Last:

First:

Middle:

a. Living:

b. Father's address when minor arrived in U.S.:

Yes

No

c. Current Address:

Unknown

Same as b. above

Section III: Immigration Data and Immigration Assistance

1. Immigration / Eligibility Data

U Status Recipient

Refugee

Cuban/Haitian Entrant-No immigration status

Asylee

Parole

SIJ (I-360 approval)

U.S. Citizen

Amerasian

Ordered Removed

Victim of Trafficking-No immigration status

Relief under Convention Against Torture

Victim of Trafficking with T-Visa

Deferred Action

Victim of Trafficking with U-Visa

Revocation of Trafficking Eligibility Letter

Legal Permanent Resident

with Immigration Status

without Immigration Status

2. Is youth receiving immigration assistance?

Yes

No

NA

*

Change in immigration/eligibility data may render a child no longer eligible for URM, particularly for Cuban/Haitian Entrants. Consult ORR.

Pro bono accredited representative

Social or legal service agency

Other:

*

URMs who become U.S. citizens are no longer eligible for URM.

Section IV: Placement Data

1. Placement Type:

2. Placement Cost: $

(average daily rate)

Relative Foster Care

Foster Care

Therapeutic Foster Care

Group Home

Semi-Independent Living

Residential Treatment

Inpatient psychiatric hospital

No Placement (enter youth living independently in Sec. VI: IL Residence and Services)

Other

3. Caregiver Residence

4. Provider Agency for Placement:

Same as placement agency

Name:

Name:

Relation of caregiver:

Address:

Address:

City:

City:

State:

Zip:

State:

Zip:

Section V: Legal Responsibility Data

1. Court with Jurisdiction:

Date Petition Filed:

Date Legal Responsibility Est.:

Pending

Name:

Address:

City:

State:

Zip Code:

2. Agency to Whom Legal Responsibility Assigned:

Name:

Address:

City:

State:

Zip Code:

3. Has Legal Responsibility Ended?

Date Ended

Yes

No

4. Voluntary Placement Agreement:

Date Signed

Yes

No

Section VI: Independent Living Residence and Services

1. Youth residence:

Address:

City:

State:

Zip Code:

2. Independent Living - URM placement has ended

Yes

Stipend Amount (monthly rate): $

Stipend Amount (avg. daily rate): $

3. Independent Living Services:

Select Funding Source

ORR

State/ Chafee

Private

Other

a. Educational benefits (Ed)

b. Independent living (IL)

Section VII: Report Submission Authority

1. Unaccompanied Refugee Minors (URM) Provider Agency:

Agency Name:

Address:

City:

State:

Zip Code:

Name

Title

Agent Approval Date

(mm/dd/yyyy)

Phone:

Email:

2. State Agency:

Agency Name:

Address:

City:

State:

Zip Code:

Name

Title

Agent Approval Date

(mm/dd/yyyy)

Phone:

Email:

Approval/Denial Comments: