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pdfOMB 0970-0554 [Valid through 02/28/2021]
Page 1 of 2
OFFICE OF REFUGEE RESETTLEMENT
Division of Children's Services
TRANSFER REQUEST AND TRACKING FORM
Minor's Profile
Alien Number
FINS Number
Last Name
First Name
AKA
Date of Placement in Current Facility
Height
Weight
DOB
Age
COB
Date of Initial Placement
Eye Color
Identifying Marks
Current Care Provider Facility
Current Program
Program Type
Address
City
Case Worker
State
Zip
Has the minor's attorney
been contacted?**
Care Provider Transfer Recommendation
Type of Facility Requested
Phone
Proposed Facility
Requestor
Request Date
Attorney of Record
Phone
ORR Transfer Decision
Name of ORR Decision Maker
Designated Care Provider Facility
Type of Care Provider Facility
New Care Provider Facility
New Program
Program Type
Secure
Address
City
State
Zip
Phone
Transfer Packet (for each minor)
Please follow checklist in the Transfer Procedures when completing
minor's transfer packet, check box to indicate the packet is completed
List of Minor's Belongings (be sure to include medication)
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR
to track the physical transfer of the UAC and their belongings. Public reporting burden for this collection of information is estimated to average 0.17 hours per
response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a mandatory
collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. If you have any comments
on this collection of information please contact [email protected].
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OFFICE OF REFUGEE RESETTLEMENT
Division of Children's Services
TRANSFER REQUEST AND TRACKING FORM
Departure/Arrival Information
Departure
Date
Time
Transportating
Staff
Name
Title
By signing below, I affirm that:
1) I have read the minor’s Case Summary and Individual Service Plan (ISP) and am aware of all documented special needs.
2) The list of the minor’s personal belongings is complete and accurate.
Signature ___________________________________________________________
Arrival
Date
Time
Receiving
Staff
Name
Date _____________________
Title
By signing below, I affirm that:
1) I have read the minor’s Case File Summary and Individual Service Plan (ISP) and am aware of all documented special needs.
2) The list of the minor’s personal belongings is complete and accurate.
Signature ___________________________________________________________
Date _____________________
Distribution of this form is restricted to ORR staff, grantees and contractors (including voluntary agencies, Child Advocates, and legal
service providers); UAC attorneys of record; the U.S. Department of Homeland Security; and the Executive Office for Immigration
Review. This form may not be distributed to any other party without the written authorization of ORR/DCS.
| File Type | application/pdf |
| File Modified | 2020-12-16 |
| File Created | 2019-06-04 |