Form ORR-3 Form ORR-3 Form ORR-3 Form

Unaccompanied Refugee Minors Program: ORR-3 Placement Report and ORR-4 Outcomes Report

ORR-3 Report Form_exp. 2.29.2024_CLEAN.xlsx

ORR-3 (Unaccompanied Refugee Minors Placement Report) - State Agencies

OMB: 0970-0034

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DEPARTMENT OF HEALTH AND HUMAN SERVICES












OMB No. 0970-0034
Office of Refugee Resettlement












Exp. 02/29/2024




























Name of Youth Alien Registration No. HHS Tracking No.
Last


First


Middle





























ORR-3 REPORT FORM
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM
PLACEMENT REPORT

















State/URD Agency
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




















Transfer to/from another URM Program









Date of Action (mm/dd/yyyy)




Transfer to


Transfer from

























State Agency:















Provider Agency:






























Change in identifying data (e.g., age, name, or A#)












Became a parent













Change in biological parent's location












Change in immigration data












Change in work authorization (i.e., Employment Authorization Document)















Change in placement type, placement cost, or youth's address














Establishment of or change in legal responsibility






























Explain "Change of Status".


































3. Termination: Date of Termination:


















Reunified with parents






Not compliant with State/Program requirement(s)






Unified with relatives





Ran away






Adopted





Departed from U.S. (Removal or Voluntary Departure)







Became a U.S. Citizen






Immigration detention






Emancipated





Incarcerated






Concluded ORR-funded services/benefits





Deceased






Left program voluntarily





Other





















Explain destination/current situation at case closure.























































































4. Re-entered for ORR-funded placement or services
Date of Re-entry (mm/dd/yyyy)











URM Placement
Services/Benefits only




































Section II: Identifying/ Basic Data

















1. Sex: 2. Date of Birth


3. Date of Eligibility


4. Date of Initial Placement




Female
Male


5a. Country of Origin:
5b. Ethnic Group:
6a. Language of Origin:
6b. Other Language(s):


















7. Eligibility Type:

Refugee

Asylee

C/H Entrant

U-Status Recipient


Trafficking Victim
Special Immigrant Juvenile (SIJ)




Afghan Humanitarian Parolee





Other:


































8. Caseworker/Provider Assessment on Personal Functioning of the Youth (complete at initial placement only):
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





Education (other than English)





Health Condition





Mental Health




























































9. URM's Children in Care:













First Name, Middle Name, Last Name Date of Birth Citizenship / Immigration Status

1st child












2nd child












3rd child






























10. 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









11. 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

















1. Immigration
















Refugee







Victim of Trafficking-No immigration status (OTIP letter only)






Asylee







U-Status Recipient





SIJ (I-360 approval)






T-Status Recipient





Afghan Humanitarian Parolee






Lawful Permanent Resident





Cuban/Haitian Entrant-No immigration status







Other:




















2. Youth is receiving immigration assistance.







* Change in immigration status may render a child no longer eligible for URM. Consult ORR immediately with questions.

Yes
No



















3. Youth has work authorization/Employment Authorization Document.







* URMs who receive U.S. citizenship are no longer eligible for URM benefits and services. They need to be terminated from the program.

Yes
No



















Section IV: Placement



























1. Placement Type:


2. Placement Cost:




(daily rate)

Foster Family Home










Therapeutic Foster Home










Group Home














Supervised Independent Living














Residential Treatment














Long-term hospitalization (more than 2 weeks)














Absent from program but legal responsibility retained














Living independently but receiving ORR-funded services/benefits














Other:






























3. Youth's Residence:
4. Provider Agency for Placement:


Name:


Same as URM Provider





Relation of caregiver:



Placement via Subcontract





Address:









City:



State:
Zip:






















Section V: Legal Responsibility















1. Legal responsibility has been petitioned.

















Yes, it was petitioned within 30 days of enrollment.






Date:






Yes, it was petitioned past 30 days of enrollment.






Date:






No, it hasn't been petitioned.





























2. Legal responsibility has been established in accordance with applicable State law.

















Yes
Date:




No
Pending


















2.a. In lieu of legal responsibility, youth has signed a Voluntary Placement Agreement.

















Yes
Date:




No



















3. Court name with jurisdiction:
































4. Agency name to whom legal responsibility assigned:











Same as URM Provider


































5. Legal responsibility has ended. Date Ended

Yes
No

















Section VI: Report Submission Authority















1. Provider Agency
































1. Provider Name















Address















City
State


Zip Code


















User Name: Title: Agency Approval Date:


(mm/dd/yyyy)
Phone:
Email:


































2. State/URD Agency
































Agency Name














Address














City
State


Zip Code


















User Name: Title: Agency Approval Date:


(mm/dd/yyyy)
Phone:
Email:

















3. ORR















Name: Title: ORR Approval Date:


(mm/dd/yyyy)
Approval/Denial Comments History:














































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