ORR-4 Report Form

ORR-3 Refugee and Entrant Unaccompanied Minor Placement Report /ORR-4 Refugee and Entrant Unaccompanied Minor Placement Report

ORR-4 Report Form 8-17-16 FINAL.xls

Title ORR-4 Regugee and Entrant Unaccompanied Minor Progress Report

OMB: 0970-0034

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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-4 REPORT FORM
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM
OUTCOMES REPORT

State Agency
URM Provider Agency



Agency Name:


Agency Name:

Address:


Address:

City:

City:
State:
Zip:

State:
Zip:

Section I: Report Action

















Check the box below to indicate the type of report supported by the Form ORR-4:

1. Annual Outcomes Report
2. Baseline Report--Youth 17 and above and submitted in conjunction with an initial ORR-3 placement report
3. Follow-up Annual Report--Former URM clients who are 17 to 21 years old and have terminated all ORR-funded services (Sections III: Education, Medical Coverage and Personal Functioning, and IV: Family Reunification Activity, are not required in follow-up reports. Please proceed to Section V)

Youth was able to participate in responding to this ORR-4: Yes No





















Date data was collected: (mm/dd/yyyy)











Age: ?










Section II: Identifying Data

















1. Date of Birth




2. Sex Female

Male




































Section III: Education, Medical Coverage and Personal Functioning of the Youth

1. Education Information:
a. Indicate the youth's current school grade level:


b. Check the appropriate box to indicate current school level and any additional curricula as appropriate:















Primary
Regular school program Provide additional curricular information:
Specialized school program



Middle
Regular school program
Specialized school program


Secondary

College bound

Vocational
GED
Postsecondary

Type of Degree Program:
Estimated Completion Date:
Not in school

Explain:
c. Has the youth required and received any educational remedial services during the reporting period?

Yes
No If yes, please specify.




d. For all youth age 16 and younger, indicate if the youth has obtained any educational or vocational skills, certificates or diplomas (including GED) since the last reporting period. For youth age 17 and above, complete Section V. Independent Living Outcomes.

Yes
No If yes, please specify.




2. Medical Coverage:


















Medicaid
ORR Funded Medical Coverage
Other
None


3. Caseworker/Provider Assessment:
Assess the youth's functioning in the following areas at an age-appropriate level on a scale of 1 through 5, as indicated below. Provide an explanation if necessary.









Poor Below Average Average Above Average Excellent Explain
English Language Skill





2
Education (other than English)





2 3 4 5
Social Adjustment





2
Health Condition





2 3 4 5
Mental Health





1 2 3 4 5
Preservation of Ethnic and Religious Heritage





2
Youth's Adherence to Safety Plan





2


Section IV: Family Reunification Activity

1. Does the youth have a current permanency plan?
Yes
No
Emancipated



















Provide the date of the most recent permanency plan review.
(mm/dd/yyyy)























2. Family reunification efforts in the U.S.
a. Are any parents or relatives in the U.S. being assessed for reunification?

Yes
No


If Yes, provide the following:


























Name:
Relationship:
Location:
Name:
Relationship:
Location:
Name:
Relationship:
Location:

















b. Have there been any significant developments?
Yes
No




If Yes, describe efforts and significant developments:




c. Has there been an explicit decision, in the past year, to not reunify a youth under 18 with:



a parent in the U.S.?
Yes
No

a relative in the U.S.? Yes
No

Explain any such decisions; include name(s), relationship(s), and reason(s) for not reunifying youth.























































3. Family tracing and reunification with relatives in other countries
a. Are any parents or relatives in other countries being assessed for reunification?
Yes
No


If Yes, provide the following:



























Name:
Relationship:
Location:
Name:
Relationship:
Location:
Name:
Relationship:
Location:

















b. Have there been any significant developments?
Yes

No




If Yes, describe efforts and significant developments:






































c. Has there been an explicit decision, in the past year, to not reunify a youth under 18 with:
a parent in another country?
Yes
No a relative in another country?
Yes
No

Explain any such decisions; include name(s), relationship(s), and reason(s) for not reunifying youth.























































4. Communication with family members
Is youth in communication with parents or relatives, in the U.S. or other countries, with whom reunification is not feasible or appropriate at this
point in time?
Yes
No

If Yes, provide the following, and include siblings or other relatives too young to serve as caregivers:

















Name:
Relationship:
Location:
Frequency:
Name:
Relationship:
Location:
Frequency:
Name:
Relationship:
Location:
Frequency:
Name:
Relationship:
Location:
Frequency:
Name:
Relationship:
Location:
Frequency:
Name:
Relationship:
Location:
Frequency:



















Section V: Independent Living Services
1. Youth residence:
Address:
City:
State:
Zip:




2. Service Type(s):

a. Youth remains in foster care






Select funding source

b. Adjudicated delinquent







ORR State/ Chafee Private NA
c. Special education







d. Independent living needs assessment




e. Academic support



f. Post-secondary educational support





g. Career preparation



h. Employment programs/vocational training






i. Budget and financial management





j. Housing education /home management training






k. Health education & risk prevention





l. Family support & healthy marriage education






m. Mentoring


n. Supervised independent living




o. Room & board financial assistance





p. Education financial assistance





q. Other financial assistance



Type:




Section VI: Independent Living Outcomes


1. Outcomes reporting status:


a. Youth participated
b. Youth declined
c. Incapacitated
d. Incarcerated
e. Runaway/missing
f. Unable to locate/invite
g. Death
(mm/dd/yyyy)

































































Data Elements Queries Responses
3. Foster care status - outcomes: Yes No Declined NA Don't Know

Youth remains in foster care


4. Current full-time employment Are you currently employed full-time?
5. Current part-time employment Are you currently employed part-time?
6. Employment-related skills In the past year, did you complete an apprenticeship, internship or other on the job training, either paid or unpaid?
7. Social Security Are you currently receiving SSI, Disability or other dependents' payments?


8. Educational aid Are you currently using a scholarship, grant, stipend, student loan, voucher or other education financial aid to cover educational expenses?


9. Public financial assistance Are you currently receiving ongoing welfare [State TANF] payments to support your basic needs?




10. Public food assistance Are you currently receiving public food assistance [SNAP or community program]?



11. Public housing assistance Are you currently receiving any sort of public housing assistance?



12. Other financial support Are you currently receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment?



13. Highest educational certification received What is the highest educational degree or certification that you have received?

a. GED





b. high school diploma

c. vocational certificate

d. vocational license

e. associate's degree

f. bachelor's degree

g. higher degree

h. none of the above

14. Current enrollment and attendance Are you currently enrolled in and attending high school, GED classes, post-high school vocational training or college?

15. Connection to adult Is there currently at least one adult in your life, other than your caseworker to whom you can go for advice or emotional support?




16. Homelessness Have you ever been homeless at any time?

17. Substance abuse referral Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling?




18. Incarceration Have you ever been confined in a jail or other correctional facility or juvenile detention in connection with allegedly committing a crime?




19. Children Have you ever given birth or fathered any children that were born?



20. Marriage at child's birth If yes, were you married to the child's other parent at the time?




21. Medicaid Are you currently on Medicaid [or use the name of the State's medical assistance program under title XIX]?




22. Other health insurance coverage Do you currently have health insurance other than Medicaid?

23. Health insurance type: Medical Does your health insurance include coverage for medical services?




24. Health insurance type: Mental health Does your health insurance include coverage for mental health services?




25. Health insurance type: Prescription drugs Does your health insurance include coverage for prescription drugs?




26. Health insurance type: Other Does your health insurance include coverage for other services, e.g., dental or vision





Other type of coverage:



Section VII: Report Submission Authority
1. Unaccompanied Refugee Minors (URM) Provider Agency:
Agency Name:

Address:

City:

State:
Zip Code:


Name Title Date (mm/dd/yyyy)



Phone:
Email:


















2. State Agency:
Agency Name:
Address:
City:

State:
Zip Code:


Name Title Date (mm/dd/yyyy)



Phone:
Email:
Approval/Denial Comments:









File Typeapplication/vnd.ms-excel
File TitleURM ORR-3 and ORR-4 Report Forms
AuthorConstance Combs
Last Modified BySarah L.
File Modified2016-08-17
File Created2009-08-31

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