ORR-6
OMB Control No. 0970-0036
Expires 02/28/2022
ORR-6 PERFORMANCE REPORT INSTRUCTIONS
General Overview
The Immigration and Nationality Actsection 412(b) (specifically, 8 U.S.C. § 1522(b)(7)(A)) authorizes the Office of Refugee Resettlement (ORR) to require that states and Replacement Designees submit performance reports for refugee assistance and services provided to eligible populations. In addition, 45 CFR § 400.28 states “ A state must submit statistical or programmatic information that the Director determines to be required to fulfill his or her responsibility under the Act on refugees who receive assistance and services which are provided….”. In an effort to streamline reporting mechanisms across ORR self-sufficiency programs, the ORR-6 Performance Report (PR) provides states/grantees an instrument that captures participation and performance statistics.
The ORR-6 has two main components: general Performance Report (PR) schedules that are tracked either semi-annually or annually and an Annual Service Plan (ASP) which is a separate component of the ORR-6 and only collected on an annual basis.
The ORR-6 Performance Report should be submitted for the following refugee benefits and assistance programs: Refugee Cash Assistance (RCA), Refugee Medical Assistance (RMA) and Medical Screening, Unaccompanied Refugee Minors (URM), and Refugee Support Services (RSS) including set-asides: Refugee School Impact (RSI) Services to Older Refugees (SOR), Youth Mentoring (YM), and Refugee Health Promotion (RHP), as well as RSS and RSS set-aside programming funded by the Afghanistan Supplemental Appropriations (ASA) Act, 2022 and the Additional Afghanistan Supplemental Appropriations Act, 2022 (hereinafter “ASA”). The ORR-6 may be used to report on future priorities as identified by the Director.
Schedules A (Narrative), B (RCA), C (Employability), D (RSS Set-Asides) and E (URM) are semi-annual reports, while Schedule F (RMA and Medical Screening) is an annual report.
The due dates for semi-annual reports (Schedules A-E) are May 31th for the reporting period October 1 – March 31 and November 30th for the reporting period April 1 – September 30.
The due date for the Annual Service Plan is November 30th for the reporting period October 1 – September 30.
The due date for Schedule F annual report is January 31st for the reporting period October 1 – September 30.
The ORR-6 Performance Report is intended to solicit participation and performance data and does not request program expenditures for the reporting period. ORR uses data gathered from the ORR-6 Performance Report to determine RCA and RMA use. State-by-State RCA, RMA and Medical Screening utilization rates derived from the ORR-6 are calculated for use in formulating program initiatives, priorities, standards, budget requests, and assistance policies. Medical Screening data is also used to monitor the performance of medical screening coordination, services, and health outcomes.
ORR populations eligible1 for refugee benefits and services includes refugees, Cuban and Haitian entrants, asylees, certain Amerasians from Vietnam who are admitted to the U.S as immigrants, certain Amerasians from Vietnam who are U.S. citizens, Iraqi and Afghan Special Immigrant Visa holders, Afghan SI/SQ Parolees, Afghan Special Immigrant Conditional Permanent Residents, Afghan Humanitarian Parolees, and victims of a severe form of human trafficking who have received certification or eligibility letters from HHS. Hereafter the term “refugee” is used to encompass all eligible persons participating in ORR refugee program services. Eligibility for the Unaccompanied Refugee Minors (URM) program includes refugees, as defined here, U status recipients, and certain Special Immigrant Juveniles who were in ORR’s Unaccompanied Alien Children’s (UAC) program or were receiving services as Cuban or Haitian entrants when they became dependent on a juvenile or family court.
ORR-6 PERFORMANCE REPORT INSTRUCTIONS
Table of Contents
Schedule A: Program Narrative ………………….………….................................................................page 03
Schedule B: Refugee Cash Assistance (RCA) ........................................................ ............. ............page 06
Schedule C: Refugee Support Services (RSS), Employability Services.............................................page 08
Schedule D: Refugee Support Services (RSS) Set-Asides
Refugee School Impact (RSI), Services to Older Refugee (SOR), Youth Mentoring (YM), and Refugee Health Promotion (RHP) …………………………..……………………………………………………......page 11
Schedule E: Unaccompanied Refugee Minors (URM) Program …..……………………………...….....page 13
Schedule F: Refugee Medical Assistance (RMA) and Medical Screening ….....................................page 20
ORR-6 Schedule A: Program Narrative Back to top page Performance Report Instructions |
Schedule A is used to collect information related to the coordination and management of the refugee resettlement program. Specifically, it collects narrative information for the Refugee Cash Assistance (RCA), Refugee Medical Assistance (RMA), Medical Screening, Refugee Support Services (RSS), Refugee School Impact (RSI), Services for Older Refugees (SOR), Youth Mentoring (YM), and Refugee Health Promotion (RHP) programs, as well as RSS and RSS set-aside programming funded by the Afghanistan Supplemental Appropriations (ASA) Act, 2022 and the Additional Afghanistan Supplemental Appropriations Act, 2022 (hereinafter “ASA”). Do not report Unaccompanied Refugee Minors (URM) information on Schedule A; provide narrative reporting for the URM program on Schedule E.
The Schedule A Program Narrative includes the following sections:
A. Activities/Accomplishments/Challenges
B. Quarterly Consultations
C. Performance Measures
D. Monitoring Activities
E. Corrective Actions
F. Optional: Client Success Stories
Narrative reporting on trends or anomalies in data and outcomes for these programs is found on Schedule B (RCA), Schedule C (Employability), Schedule D (RSS Set-Asides), and Schedule F (RMA and Medical Screening). Utilize Schedule A to report on broader programmatic trends, accomplishments, challenges, and other program management and coordination activities.
Note: Do not include any Personally Identifiable Information (PII) (e.g., client name, A #, country of origin, date of birth) in any section of Schedule A. Use general categorical information (e.g., use “refugee,” instead of a client’s name).
General Information: Enter the following information at the top of the report:
Item |
Data Element |
Instructions |
1. |
Reporting Period |
Indicate the numbered period (1, 2) that corresponds to the reporting period represented in the report. |
2. |
Fiscal Year |
Enter the federal fiscal year represented in the report. |
3. |
State/Grantee |
Enter the name of the state or grantee that is providing the data. |
4. |
Date |
Enter the date the form is completed. |
Schedule A: Program Narrative |
Section A: Please complete each part according to the provided instructions. Expand space as necessary for each program reported.
Program: When reporting on program(s), including priority component(s) and initiative(s), for Sections A, utilize the following list:
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Activities: When reporting on activities for each program in Section A, utilize the following list of sample topics.
Topic Options for Activities - Section A |
Topic Definition |
Community Resources for Clients |
Community resources for clients refers to the accessibility and availability of non-ORR services or programs for clients |
Documentation/Records Management |
Documentation/Records management refers to the maintenance and organization of case and program level documentation (e.g.. case files, database, confidentiality, etc.) |
Eligibility |
Eligibility refers to the determination or documentation of eligibility of ORR programs and services |
Financial Administration |
Financial Administration refers to the financial responsibilities related to administering refugee assistance programs (e.g., benefits oversight, budget, donations, allocations to sub-grantees, etc.) |
Program Administration |
Program administration refers to broad and overarching categories related to the administration of refugee assistance programs by states and state-alternative agencies (e.g., policies, program coordination, staffing, consultations, out-migration, etc.) |
Program Development |
Program development refers to building capacity and support for refugee assistance programs (e.g., outreach/education, partnerships, etc.) |
Reporting |
Reporting refers to the reporting requirements related to refugee assistance programs (e.g., programmatic reporting and financial reporting to ORR, monitoring, etc.) |
Services |
Services refer to the services and benefits specific to refugee assistance programs (e.g., health, employment, social, case management, housing, etc.) |
Other |
“Other” is used to document accomplishments, challenges and promising practices that do not specifically relate to the above mentioned topics |
Accomplishments and new initiatives: Report any accomplishments in the administration or implementation of the refugee program, including those related to the annual outcome goals and objectives that the state/grantee has proposed, as well as any interim objectives achieved within the reporting period. Also include accomplishments that focus on activities undertaken towards aiding refugees in attaining self-sufficiency and integration.
4. Challenges and Emerging Issues: Report any challenges or emerging issues in the administration or implementation of the refugee program, including those related to the annual outcome goals and objectives that the state/grantee has proposed. Challenges should focus on impediments for refugees attaining self-sufficiency and integration. Report on challenges already shared with ORR Regional Staff as well as emerging issues not yet reported.
Section B: Quarterly Consultations: ORR regulations require states to convene quarterly consultations with local stakeholders. In this section, report details related to the quarterly consultations conducted during the reporting period.
Item |
Data Element |
Instructions |
1. |
Number of consultations in the state during the reporting period |
Provide total number of all consultations, include all consultations whether they are statewide, regional, or local. |
2. |
List of cities/dates where consultations were held |
Provide the name of each city along with date where and when the consultation occurred, if multiple consultations occurred in the same city, list all dates associated with that city. |
3. |
General description of stakeholders who attended consultations |
Provide general description of stakeholders who attended reported consultations (such as Refugee Health Coordinator, federal agencies, state/local government; local stakeholders such as resettlement agencies, education, public health, safety, housing, social service agencies, etc. |
4. |
Main issues discussed in the consultations |
Provide general description of issues and/or topics discussed in various consultations, such as arrival patterns, demographics, health, local capacity, resettlement barriers, etc. |
Section C: Performance Measures: Describe performance measures the state or a grantee uses to measure performance among ORR-funded service providers, such as performance improvement measures, for the RCA, RMA, Medical Screening, RSS, RSS set-aside, ASA RSS, and ASA-funded RSS set-aside programs.
Section D: Monitoring Activities: List monitoring activities undertaken during the reporting period of the state’s or grantee’s sub-grantees for the RCA, RMA, Medical Screening, RSS, RSS set-aside, ASA RSS, and ASA-funded RSS set-aside programs. Indicate the following:
Item |
Data Element |
Instructions |
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Agency Name |
Indicate the name of the agency that was monitored |
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Program |
Indicate the program(s) that were monitored (RCA, RMA, Medical Screening, RSS, RSI, SOR, YM, RHP, ASA RSS, and ASA-funded RSS set-aside programs) |
3. |
Location |
Indicate the city/state of agency/program that was monitored |
4. |
Date |
Indicate the date(s) of the monitoring |
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Purpose |
Indicate the purpose of the monitoring (regularly scheduled monitoring, corrective action follow-up, new director, etc.) |
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Corrective Action Identified? (Yes/No) |
Indicate if any corrective action(s) were identified during the monitoring trip (Yes/No) Attach to Schedule A any monitoring reports from this reporting period that include corrective actions (Corrective Action Identified = Yes). Monitoring reports from the reporting period that did not include corrective action do not need to be submitted to ORR. |
Section E: Corrective Actions: Discuss the results of follow-up to corrective action plans identified in previous reporting periods.
Section F: Optional: Client Success Stories: In detailed narrative, provide a success story or stories of refugees who received service in RCA, RMA, Medical Screening, RSS, RSI, SOR, YM, RHP, ASA RSS, ARSI, ASOR, AYM, or ARHP during this reporting period. This is an optional question and information collected in this question may be used by ORR communications or reporting. If used, ORR will be in touch to obtain more information, and necessary permissions, if applicable.
ORR-6 Schedule B: Refugee Cash Assistance (RCA) Back to top page Performance Report Instructions |
Schedule B: Refugee Cash Assistance
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Schedule B is used to report utilization of Refugee Cash Assistance (45 CFR 400 Subpart E) funded by ORR to eligible populations, regardless of the type of program operated in the state (State Administered, Replacement Designee or Public-Private Partnership).
General Information: Enter the following information at the top of the report:
Item |
Data Element |
Instructions |
1. |
Reporting Period |
Indicate the numbered period (1, 2) that corresponds to the reporting period represented in the report |
2. |
Fiscal Year |
Enter the federal fiscal year represented in the report |
3. |
State/Grantee |
Enter the name of the state or grantee that is providing the data |
4. |
Date |
Enter the date the form is completed |
Sections A-D: Please fill out each section according to the provided instructions. Pay attention to the required data components that request unduplicated numbers.
A: Refugee Cash Assistance Participation
In this section, ORR is seeking information on the number of RCA recipients enrolled during the reporting period.
Item |
Data Element |
Instructions |
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Previous RCA recipients still enrolled in this reporting period |
Enter the unduplicated number of cases and the number of persons who were reported as RCA recipients in the previous reporting period and are still receiving RCA in this reporting period, even for a portion of the reporting period. |
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New RCA recipients during this reporting period |
Enter the unduplicated number of persons by the type of enrollment (new arrivals, or others) added to RCA during this reporting period who were not reported in the previous reporting period. Also enter the total number of new RCA cases. |
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Total number of RCA recipients during this reporting period |
Provide the breakdown of the number of persons for each case size (1 - 4) who were on RCA at any time during this reporting period. Total number of persons reported under 1-4 case size breakdowns should match total number of cases and persons reported in the previous items A. 1. and A. 2. |
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Total unduplicated number of TANF-type recipients (including differential) Federal Fiscal Year To Date
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For programs which are approved to provide RCA payment and/or differential for TANF eligible refugees, provide total unduplicated number of TANF-type recipients (including those receiving differential payments) who received RCA Federal Fiscal Year-To-Date. |
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Total Unduplicated number of RCA-type recipients Federal Fiscal Year To Date |
Provide total unduplicated number of RCA-type recipients Federal Fiscal Year To Date. |
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Total Unduplicated number of RCA recipients Federal Fiscal Year To Date |
Total will auto-calculate unduplicated TANF-type recipients (A. 4.) and RCA-type recipients (A. 5.). |
B: Exemptions
In this section, number of persons exempted from registration for employment services (45 CFR §400.76) from RCA recipients reported during this period (A.3).
Item |
Data Element |
Instructions |
B. 1. |
Reasons for Exemption |
State the exemption reasons (1 - 6). Be concise, if there are more than 5 types of exemptions report under “other”. |
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Total Number of Exemptions |
Enter total number of individual exemptions under each type of exemption. |
B. 3. |
Total Exemptions from employment services |
Report will automatically calculate total number of exemptions reported. |
C: Refugee Cash Assistance Efficiency
Information provided in this section should include unduplicated information.
Item |
Data Element |
Instructions |
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Number of RCA recipients who reached the eight month time limit |
Enter the total number of RCA recipients who received RCA at any point during the first eight months since arrival (regardless when and how long they received RCA), who are between 18 and 65, and who are not exempt under §400.76 and who reached eight months since arrival during this reporting period. To clarify, the RCA recipient does not have to be a recipient of RCA at the end of eight month, but the recipient has to have received RCA during the first eight months after arrival. The length of RCA receipt (1 day, 1 week, or 1 month) is irrelevant. |
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Number of RCA terminations due to income from employment prior to the eight month limit |
Enter the total number of RCA terminations due to income from employment for those RCA recipients reported under C.1., regardless if termination occurred in the reporting period or at any point earlier. Do not include any other termination, such as sanction, out-migration, time expiration, etc. Since refugees reach only once eight months mark, this data should be unduplicated throughout the fiscal year. If a refugee has obtained a job in the last month before the eight month mark, but has already received RCA payment for that month, then refugee would not be counted for this report area. A grant termination is defined as the closing of a cash assistance case due to earned income from employment in an amount that exceeds the state's eligibility standard for the case based on family size, rendering the case over-income for cash assistance. |
C. 3. |
RCA termination Rate |
Report will automatically calculate termination rates. |
D: Trends
Analyze and reflect on the data reported in sections A, B, and C. Report overall observations in data trends and explain any anomalies in data.
ORR-6 Schedule C: Employability Services Back to top page Performance Report Instructions |
Schedule C is used to report outcomes from employability services (45 CFR § 400.154) funded by ORR to eligible populations. This report includes employment services outcomes from the RSS grant and ASA RSS funding. The employment services outcomes reported on this form are those directly related to job placements (e.g. direct services provided in accordance with employability plans to enable an individual to obtain employment). Entered Employment is defined as the entry of an active employment services participant into unsubsidized employment for at least one day during the period. States/grantees should report only on entered employment during the reporting period in this item for each active employment services participant. Include in this item those active participants who were placed directly by a service provider through a documented referral, those who obtained employment on their own, and those who entered unsubsidized employment as a result of On-the-Job Training (OJT). An individual participating in OJT may not be counted in “entered employment” until the period of subsidized employment is completed and the employer has agreed to retain the individual in an unsubsidized permanent position. Unsubsidized job placements that occur while an active participant is enrolled in English Language Instruction (ELI) or when an active participant completes Vocational Training (VT) are counted as entered employments in the reporting period in which they occur.
Note: At the time an active employment services participant is placed in employment, verification of the individual's cash assistance status is required. The state/grantee may count only one placement per reporting period for any client, but the state/grantee may enter another placement for the client in a subsequent period.
General Information: Prior to completing Sections A-C, enter the following information at the top of the report:
Item |
Data Element |
Instructions |
1. |
Reporting Period |
Indicate the numbered period (1, 2) that corresponds to the reporting period represented in the report. |
2. |
Fiscal Year |
Enter the Federal fiscal year represented in the report. |
3. |
State/Grantee |
Enter the name of the State, or name of grantee if not a State, that is providing the data. |
4. |
Date |
Enter the date the form is completed. |
5. |
Grant Name |
Enter the ORR grant name. |
Schedule C: Employability Services 45 CFR § 400.154
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Sections A-C: Please fill out each section according to the provided instructions. Pay attention to the required data components that request unduplicated numbers.
A: Participation Totals Under 45 CFR §§ 400.154 (a)(c)(d) and (e)
Item |
Data Element |
Instructions |
A. 1. - 4. |
Employability Services |
Enter the total unduplicated number of participants (1-4) served in these employability services during the reporting period: Employment services, On-the-job Training, English Language Instruction, and Vocational training. [45 CFR §§ 400.154 (a) (c) (d) and (e)]. If the same participant receives more than one of these services, report them under each service received and ensure unduplicated count for each service. |
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Total Reporting Period Unduplicated |
Unduplicate across all four services and enter unduplicated number of participants reported under A. 1. - 4. during the reporting period. |
B: Employment Services
In this section, provide the requested number with unduplicated information on employment service participants distinguished by type of cash assistance they receive: RCA, TANF, or No Federal Cash Assistance. Participants should be reported by the cash assistance status at the end of reporting period.
RCA clients- include the number of employment service participants receiving RCA assistance.
TANF clients-include the number of employment service participants receiving TANF assistance.
No federal cash assistance is used to distinguish refugees who enter employment before receipt of cash assistance, such as refugees in their first month after arrival and others who are no longer eligible for assistance such as working clients who receive a job upgrade, clients who follow their spouses into the workforce after benefits are terminated, and clients who do not find work until after termination of assistance. For example, a refugee who finds full-time employment in the first month would be reported in item B.1. c. 0-12 months, etc.
Item |
Data Element |
Instructions |
B. 1. a. -1. c. |
Total Number |
Enter total unduplicated number of employment services participants for each B. a., B. b., and B. c. The sum of B. a. through B. c. should total in line B. d. representing total employment services caseload at the time of this report. The caseload consists of active employment services participants as defined in 45 CFR § 400.154 (a) ONLY. An active participant is defined as a person with whom the provider has direct, regular contact for the purpose of providing these employment services: development of a family self-sufficiency plan and an individual employability plan, world-of-work and job orientation, job clubs, job workshops, job development, referral to job opportunities, job search, and job placement and follow up. For example, according to 45 CFR § 400.75 (a) 1. an RCA client, unless exempt from employment services as detailed in the State Plan, is required to enroll in employment services [as defined in 45 CFR § 400.154 (a)], and, therefore, should be included in the total caseload. Information on Matching Grant Program clients should not be reported in the total employment caseload count (B.1.). |
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Full-Time Employment |
Enter the number of full-time job placements during the reporting period by cash assistance status (RCA, TANF, and No Federal Cash Assistance) at the time of job placement. Full-time is defined as 35 hours or more per week. |
B. 3. |
Part-Time Employment |
Enter the number of part-time job placements during the reporting period by cash assistance status (RCA, TANF, and No Federal Cash Assistance) at the time of job placement. Part-time employment is defined as fewer than 35 hours per week. |
B. 4. |
Grant Terminations |
Enter the number of grant terminations achieved through entered employments by cash assistance status (RCA, TANF). A grant termination is defined as the closing of a cash assistance case due to earned income from employment in an amount that exceeds the state's eligibility standard for the case based on family size, rendering the case over-income for cash assistance. If the net earned income exceeds the eligibility standard, the case should be considered a grant termination. The grant termination caseload should be out of the full-time and part-time employment caseload. |
B. e (2. - 3.) |
Average Hourly Wage at Employment Entry |
Enter the average hourly wage at the time employment begins for all full-time and part-time individuals entering employment in the reporting period. To calculate this wage, add the hourly wage for all individuals placed in full-time, unsubsidized employment as reported in the Total for Item B.2., and divide the sum by the total number of individuals who entered full-time employment as reported in Item B.2. Use the same methodology to calculate average hourly part-time wages using the data reported in the Total for Item B.3. (Part-time). Note: If the refugee is placed in multiple jobs during the reporting period, you may use the highest wage earned. Hourly wages may be converted from monthly wages or from piece rates or a combination of both. If piece rates are used, determine the expected number of items to be produced in an hour and multiply it by the piece rate quoted by the employer at the time of placement. |
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Health Benefits Available |
Enter the number of refugees entering full-time employment where health benefits are offered. This item captures data on the availability of health benefits for those individuals who entered full-time employment. This is not a measure of how many individuals elect to enroll in health benefits, but rather how many jobs offer this option, either at placement or within 6 months of placement. Benefits should be considered available if self-only coverage is available to the employee even if coverage is not extended to the employee's family members. Benefits are considered available without regard to whether the employee must contribute to the premium. Note: If the refugee is placed in multiple jobs during the reporting period, you may count any employment opportunity that offered health benefits. |
B. g. (2. - 3.) |
Employed 90 Days Later |
Enter the number of individuals by category of employment (full- or part-time), who were employed on the 90th day after entering employment. This item is a measure of continued participation in the labor market, not retention of a specific job. "Employed 90 Days Later" means that an individual is working for wages on the 90th day after having entered employment at any unsubsidized job. Where there have been multiple placements with the same individual within the same reporting period, the date of the first employment entry is the start date for calculating the 90-day follow-up. An individual who is on strike on the 90th day is considered employed. An individual who has been laid off and does not anticipate returning to the same employer within 30 days is considered unemployed. |
C: Trends
Analyze and reflect on the data reported in sections A-B. Report overall observations in data trends and explain any anomalies in data.
ORR-6 Schedule D: Refugee Support Services (RSS) Set-Asides Back to top page Refugee School Impact (RSI), Services to Older Refugees (SOR), Youth Mentoring (YM), and Refugee Health Promotion (RHP) Performance Report Instructions |
Schedule D should be filled out by states/grantees that currently operate a refugee support services (RSS) set-aside program (including one or more ASA-funded RSS set-aside programs) as determined by ORR set-aside formula allocations Schedule D should be completed with each ORR-6 submission. This is a cumulative report, second semi-annual report should account for all served in the Federal Fiscal Year.
General Information: Prior to completing Sections A-D, enter the following information at the top of the report:
Item |
Data Element |
Instructions |
1. |
Program Name |
Indicate the name of the set-aside program (e.g.: RSI, SOR, ARSI, ASOR) that corresponds to the program represented in the report. |
2. |
Reporting Period |
Indicate the numbered period (1, 2) that corresponds to the reporting period represented in the report. |
3. |
Fiscal Year |
Enter the Federal fiscal year represented in the report. |
4. |
State/Grantee |
Enter the name of the State, or name of grantee if not a State, that is providing the data. |
5. |
Date |
Enter the date the form is completed. |
Schedule D: Refugee Support Services (RSS) Set-Asides
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Sections A, B: In these sections, complete unduplicated year-to-date participation in applicable services and provide breakdown by type of participant and service provider. Report in Sections A and B all participants served throughout the reporting period. Enter the number of male (M) and female (F) participants. Use “other” for type of client and/or service provider as appropriate.
Item |
Data Element |
Instructions |
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Type of the Participant |
Enter the unduplicated number of male and female participants by the type of program participant 1. – 5. (Student, parent, older refugee, etc.). Totals will automatically calculate for each type of participant.
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Primary Contracted Service Provider |
Enter the total unduplicated number of male and female participants who received services from the contracted service providers. Same participant could be served by one or more contracted service providers, report under each when appropriate. For the School Impact program, if the provider is other than school or Resettlement Agency, provide the name under “Other Local Agency” and report number of served participants. School: Enter the total unduplicated number of youth who received services through schools (public or private) in the appropriate school service provider category, by their respective grade (K-5, 6-8, and 9-12). During the summer months when school is off, report under next grade to attend. Same student could be served by both, the school and Resettlement Agency, report under each if appropriate. Area Agency on Aging: Enter the total unduplicated number of older refugees served by contracted Area Agencies on Aging and/or other contracted local service providers (provide the name under “Other Local Agency” and report number of served participants). Totals will auto calculate for each type of service provider. |
Section C: For each category under this section, report the total number of completions during the reporting period for each male and female participant. Totals will automatically calculate for each completion.
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Parent/Student Orientation |
Enter the number of males and females who completed a formal orientation hosted by one of the identified service providers during the reporting period. This item should include those who successfully completed the orientation and not those that registered but did not attend or did not complete the orientation during the reporting period. Report both students and parents. |
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Grade Promotion |
Enter the number of male and female youth program participants who were successfully promoted to the next grade at the end of the school year that falls within the current reporting period. |
C. 3. |
SSI |
Enter the number of male and female program participants who were assisted to apply for Supplemental Security Income (SSI) and successfully approved for SSI as a result of ORR-funded provider services during the reporting period. |
C. 4. |
Citizenship |
Enter the number of male and female program participants who passed U.S. Citizenship test as a result of ORR-funded provider services during the reporting period. |
C. 5. – 7. |
Other |
Enter the number of male and female program participants who completed any other service (provide the name of each service under C. 5. - 8.) |
D: Trends
Analyze and reflect on the data reported in sections A, B, and C. Report overall observations in data trends and explain any anomalies in data, including trends based on new program components and/or initiatives.
ORR-6 Schedule E: Unaccompanied Refugee Minors (URM) Program Back to top page Performance Report Instructions |
Schedule E is used to collect performance data related to placements and services provided to eligible clients of the Unaccompanied Refugee Minors (URM) program. Schedule E must be completed and submitted by States that operate a URM program that has been approved via their current State Plan pursuant to 45 CFR 400.5(e). Schedule E must be completed and submitted per location (i.e. city) where URM services are provided. If a URM provider has a sub-office location in another part of the state, a distinct Schedule E must be submitted separately from the main office location. Schedule E must include URM clients only who are receiving ORR-funded placement and/or services, including stipend(s) for independent living, education and training. Schedule E must not include non-URM children/youth for which the state receives Title IV-E reimbursement or unaccompanied alien children (UAC) currently in federal custody.
Schedule E is a two-part report that includes a data report and a narrative report. The Schedule E URM Program Data has four sections: A. Snapshot of Caseload, B. New Enrollments by Eligibility, C. Major Outcomes for Applicable Terminated Clients, and D. Placements and Capacity Development. The Schedule E URM Program Narrative has six sections: A. Activities, B. Accomplishments / New Initiatives, C. Challenges / Emerging Issues, D. Trends / Clarifications in Data, E. Monitoring / State Licensing Reviews, and F. Client Success Story or Promising Practice.
Note: Do not include any Personally Identifiable Information (e.g. client name, A #, country of origin, date of birth) in any section of the Schedule E. Submit an unduplicated client count per report; do not double count clients who terminate and re-enter the program for placement and/or services in the same reporting period.
General Information: Enter the following information at the top of the URM Program Data and URM Program Narrative reports:
Item |
Data Element |
Instructions |
1. |
State/Grantee |
Enter the name of the state or grantee that is providing the data. |
2. |
Fiscal Year |
Enter the federal fiscal year represented in the report. |
3. |
Reporting Period |
Enter the numbered period (1, 2) that corresponds to the reporting period represented in the report. |
4. |
Provider |
Enter the name of the URM provider agency. |
5. |
Location |
Enter the city where the URM services were provided. |
ORR-6 Schedule E: URM Program Data |
Sections A-D: Please complete each section according to the provided instructions.
A: Snapshot of Caseload
Item |
Data Element |
Instructions |
|
Clients at the Beginning of Reporting Period |
Enter the number of clients receiving ORR-funded placement and/or services in this location at the beginning of the reporting period. Include: any client that is in a licensed placement (e.g., foster home, group home); any client that has aged out of placement services but is receiving ORR-funded Independent Living (IL)/Education services and benefits such as Education and Training Vouchers (ETVs); and any client that is absent from placement services but for whom legal responsibility is retained (e.g., a client under the age of 18 who ran away). |
|
Newly Enrolled |
Enter the number of clients who were newly enrolled in this location in the reporting period. Include unaccompanied refugee minors who arrived from overseas, and other eligible populations approved for URM placement and services by ORR. |
|
Re-entered Placement |
Enter the number of clients who re-entered for placement in the reporting period after termination in a previous reporting period. Do not include clients who both terminated and re-entered for placement in the reporting period. These clients have already been captured A.1. Clients at the Beginning of Reporting Period. |
|
Re-entered for ORR-funded IL/Education Services only |
Enter the number of clients who re-entered in the reporting period to receive ORR-funded IL/Education Services only (e.g., living stipend, ETV) after termination in a previous reporting period. Do not include clients who both terminated and re-entered for services in the reporting period. These clients have already been captured A.1. Clients at the Beginning of Reporting Period. |
|
Terminated from ORR-funded Placement and Services |
Enter the number of clients who were terminated from all ORR-funded placement and services in the reporting period and did not re-enter the program in the reporting period. Do not include clients who emancipated from placement but are receiving ORR-funded IL/Education Services (e.g., living stipend, ETV.) Do not include clients who both terminated and then re-entered in the reporting period. |
|
Total Clients at the End of Reporting Period |
Do not enter any number in this field. Once A.1. – A.5. are completed, the total in A.6. will auto-calculate. Note: The number of Total Clients at the End of Reporting Period in the Reporting Period 1 report should match the number of Clients at the Beginning of Reporting Period in the Reporting Period 2 report. If the number does not match, provide a written explanation in URM Program Narrative, section C. |
B: New Enrollments by Eligibility2
In Section B enter the data per URM provider location as previously instructed.
Item |
Data Element |
Instructions |
|
This Period |
Enter the number of newly enrolled clients by eligibility type in this location in the reporting period. |
B. 1. a. |
Asylee |
Enter the number of newly enrolled clients in the reporting period that have an asylum letter from the U.S. Citizenship and Immigration Services (USCIS) or an immigration judge’s order granting asylum. |
B. 2. a. |
Cuban/Haitian Entrant |
Enter the number of newly enrolled clients in the reporting period that have an I-94, parole, Notice to Appear or other document establishing him/ her as a Cuban/Haitian Entrant. |
B. 3. a. |
Refugee |
Enter the number of newly enrolled clients in the reporting period that have an I-94 documenting refugee status. |
B. 4. a. |
Special Immigrant Juvenile |
Enter the number of newly enrolled clients in the reporting period that have documentation of USCIS approval of an I-360 petition. |
B. 5. a. |
Victim of Human Trafficking |
Enter the number of newly enrolled clients in the reporting period that have a letter of eligibility issued by the Office of Trafficking in Persons (OTIP) or a T-visa. |
B. 6. a. |
U-status Recipient |
Enter the number of newly enrolled clients in the reporting period that have received documentation of U status from USCIS or U-visa. |
B. 7. a |
Afghan Humanitarian Parolee |
Enter the number of newly enrolled clients in the reporting period that have a Form I-94 or a foreign passport with admission stamp with any of the following notations: “OAR,” “OAW,” “DT,” or “INA section 212(d)(5)(A).” |
B. 8. a. |
Other |
Enter the number of newly enrolled clients in the reporting period that do not fall into one of the above eligibility categories (e.g. Afghan SIV derivatives). |
B. 9. a. |
Total Enrolled |
Do not enter any number in this field. Once fields B.1.a. – B.8.a. are completed for each report period, the total will auto-calculate. |
B. b. |
Year-to-Date |
Enter the number of newly enrolled clients by eligibility type in this location in the fiscal year. Note: For Reporting Period 1 report, numbers of newly enrolled clients by eligibility entered in the Year-to-Date column should match the numbers entered in the This Period column. For Reporting Period 2 report, the numbers entered in the Year-to-Date column should represent a cumulative, unduplicated count of all clients newly enrolled in the fiscal year. |
B. 1. b. |
Asylee |
Enter the number of newly enrolled clients in the fiscal year that have an asylum letter from the U.S. Citizenship and Immigration Services (USCIS) or an immigration judge’s order granting asylum. |
B. 2. b. |
Cuban/Haitian Entrant |
Enter the number of newly enrolled clients in the fiscal year that have an I-94, parole, Notice to Appear or other document establishing him/ her as a Cuban/Haitian Entrant. |
B. 3. b. |
Refugee |
Enter the number of newly enrolled clients in the fiscal year that have an I-94 documenting refugee status. |
B. 4. b. |
Special Immigrant Juvenile |
Enter the number of newly enrolled clients in the fiscal year that have documentation of USCIS approval of an I-360 petition. |
B. 5. b. |
Victim of Human Trafficking |
Enter the number of newly enrolled clients in the fiscal year that have a letter of eligibility issued by the Office of Trafficking in Persons (OTIP) or a T-visa. |
B. 6. b. |
U-status Recipient |
Enter the number of newly enrolled clients in the fiscal year that have received documentation of U status from USCIS or U-visa. |
B. 7. b |
Afghan Humanitarian Parolee |
Enter the number of newly enrolled clients in the fiscal year that have a Form I-94 or a foreign passport with admission stamp with any of the following notations: “OAR,” “OAW,” “DT,” or “INA section 212(d)(5)(A).” |
B. 8. b. |
Other |
Enter the number of newly enrolled clients in the reporting period that do not fall into one of the above eligibility categories (e.g. Afghan SIV derivatives). |
B. 9. b. |
Total Enrolled |
Do not enter any number in this field. Once fields B.1.b. – B.8.b. are completed for the fiscal year, the total will auto-calculate. |
C: Major Outcomes for Applicable Terminated Clients
In Section C, include only URM clients who terminated from all ORR-funded services and benefits in this location in the reporting period who achieved at least one major outcome. One client may have achieved multiple outcomes at the point of termination. Record all outcomes for each applicable terminated client.
Item |
Data Element |
Instructions |
|
C. 1. |
Eligibility Type |
Enter eligibility type for each terminated client using the following acronyms: |
|
|
|
||
C. 2. |
GED completion |
Enter “1” if terminated client passed General Education Development (GED) test and holds a GED certificate. |
|
C. 3. |
HS Diploma |
Enter “1” if terminated client earned a high school diploma. |
|
C. 4. |
2-Year College |
Enter “1” if terminated client enrolled in or graduated from a 2-year college. |
|
C. 5. |
4-Year College |
Enter “1” if terminated client enrolled in or graduated from a 4-year college. |
|
C. 6. |
Vocational Certificate |
Enter “1” if terminated client earned any vocational certificate (e.g. auto mechanics, hair stylist). |
|
C. 7. |
Job Corps/Other |
Enter “1” if terminated client enrolled in or completed Job Corps or other similar job training program. |
|
C. 8. |
Part-Time Employment |
Enter “1” if terminated client is employed on a part-time basis (i.e. less than 35 hours per week.) |
|
C. 9. |
Full-Time Employment |
Enter “1” if terminated client is employed on a full-time basis (i.e. more than 35 hours per week.) |
|
C. 10. |
Family Reunification/ Unification |
Enter “1” if terminated client was reunified with a parent or unified with other relatives. |
|
C. 11. |
Adoption |
Enter “1” if terminated client was adopted or adoption is in the process. |
|
C. 12. |
Total Outcomes |
Once fields C.2. – C.11. are completed, the totals will auto-calculate. |
|
D. Placements and Capacity Development
In Section D enter the data per URM provider location as previously instructed.
Item |
Data Element |
Instructions |
D. 1. |
Client Placements at End of Reporting Period |
Enter the number of clients in ORR-funded placements, per placement category, at the end of the reporting period. If a client had been in more than one placement during the reporting period, only count the placement that the client was in on the last day of the reporting period. |
D. 1. a. |
Foster Home |
Enter the number of clients who were placed in a foster home including a relative foster home (e.g., kinship care) at the end of the reporting period. |
D. 1. b. |
Therapeutic Foster Home |
Enter the number of clients who were placed in a therapeutic foster home at the end of the reporting period. |
D. 1. c. |
Semi-independent Living |
Enter the number of clients who were placed in semi-independent living at the end of the reporting period.
|
D. 1. d. |
Group Home |
Enter the number of clients who were placed in a group home at the end of the reporting period. |
D. 1. e. |
Residential Treatment |
Enter the number of clients who were placed in a residential treatment center at the end of the reporting period. |
D. 1. f. |
Living Independently |
Enter the number of clients living independently at the end of the reporting period.
Note: Clients living independently may or may not be receiving an ORR-funded living allowance or stipend. In addition, clients living independently may only be receiving an ORR-funded ETV, without a stipend specifically for living expenses. |
D. 2. |
Newly Developed Capacity |
Enter the number of newly developed placements by type that became available in the reporting period but have not yet been used in placing a client. Examples include newly licensed foster homes, or group homes made available through sub-contract agreements. Note: Do not enter a number in D.2.f. Living Independently as it is not applicable to newly developed capacity. |
D. 2. a. |
Foster Home |
Enter the number of newly developed foster home placements that became available in the reporting period but have not yet been used in placing a client. |
D. 2. b. |
Therapeutic Foster Home |
Enter the number of newly developed therapeutic foster home placements that became available in the reporting period but have not yet been used in placing a client. |
D. 2. c. |
Semi-independent Living |
Enter the number of newly developed semi-independent living placements that became available in the reporting period but have not yet been used in placing a client. |
D. 2. d. |
Group Home |
Enter the number of newly developed group home placements that became available in the reporting period but have not yet been used in placing a client. |
D. 2. e. |
Residential Treatment |
Enter the number of newly developed residential treatment placements that became available in the reporting period but have not yet been used in placing a client. |
D. 3. |
Capacity in Development |
Enter the number of placements in development by type which may become available to place clients in the next reporting period. Examples include number of families who are actively participating in pre-service training and may become licensed foster homes, or group home placements that may become available in the next reporting period. Report on capacity development activities for which prospects are not yet known in the URM Program Narrative. Note: Do not enter a number in D.3.f. Living Independently as it is not applicable to capacity in development. |
D. 3. a. |
Foster Home |
Enter the number of foster home placements in development which may become available to place clients in the next reporting period. |
D. 3. b. |
Therapeutic Foster Home |
Enter the number of therapeutic foster home placements in development which may become available to place clients in the next reporting period. |
D. 3. c. |
Semi-independent Living |
Enter the number of semi-independent living placements in development which may become available to place clients in the next reporting period. |
D. 3. d. |
Group Home |
Enter the number of group home placements in development which may become available to place clients in the next reporting period. |
D. 3. e. |
Residential Treatment |
Enter the number of residential treatment placements in development which may become available to place clients in the next reporting period. |
ORR-6 Schedule E: URM Program Narrative |
Sections A-F: Please complete each section according to the provided instructions.
Utilize the following list of topic areas when completing Sections A-C. More than one topic may be applicable for each section.
Topic Areas for Sections A-C |
Topic Definition |
Client Caseload |
Client Caseload refers to the make-up of the clients being served by the URM provider (e.g., increases or decreases in certain eligibility types, diversification of client caseload, trends in terminations, etc.) |
Documentation/Records Management |
Documentation/Records Management refers to the maintenance and organization of case and program level documentation (e.g., case files, database, confidentiality, etc.) |
Financial Administration |
Financial Administration refers to the financial responsibilities related to administering the URM program (e.g., budgets, expenditure tracking, reimbursement to URM providers, monitoring cost effectiveness of program, etc.) |
Program Administration |
Program Administration refers to categories related to the administration of the URM program by states or state-alternative agencies (e.g. policies/protocols, program coordination, program structure, staffing, consultations, monitoring/oversight activities, etc.) |
Program Development |
Program Development refers to categories related to the development of the URM program (e.g., increased placement capacity, diversification of placements, training of URM provider staff and foster parents, outreach/education to stakeholders, building new partnerships, etc.) |
Reporting |
Reporting refers to the reporting requirements related to the URM program (e.g., case, programmatic, and financial reporting to ORR; response to ORR monitoring; reporting for state licensing, etc.) |
Services / Benefits |
Services / Benefits refer to the provision of services and benefits to URM clients (e.g., foster placements, medical, mental health, education, vocational, independent living, social, preservation of heritage culture and religion, etc.) Include availability and accessibility of non-ORR services and programs for URM clients. |
Item |
Data Element |
Instructions |
A. |
Activities |
Report any activities in the administration or implementation of the Unaccompanied Refugee Minors Program, in any of the topics areas noted above.
Example: In the area of Services/Benefits, URM provider coordinated a holiday cultural celebration for URM clients and their foster families in December. At the event URM youth showcased food, music and traditional clothing from their heritage cultures. Approximately 100 youth and foster families attended the celebration. |
B. |
Accomplishments / New Initiatives |
Report any accomplishments or new initiatives in the administration or implementation of the Unaccompanied Refugee Minors Program, in any of the topic areas noted above. Include any outcome or impact of the accomplishment or new initiative.
Example: In the area of Program Development, URM provider executed a Memorandum of Understanding with Happy Day Therapeutic Group Home. Two URM clients in need of therapeutic group care were placed in the Happy Day Group Home in the reporting period. After meeting treatment goals in the group home, one of the clients was moved back to his foster home placement. |
C. |
Challenges / Emerging Issues |
Report any challenges or emerging issues in the administration or implementation of the Unaccompanied Refugee Minors Program, in any of the topic areas noted above. Include any actions taken, resolutions achieved, or plan to address the challenge or emerging issue.
Example: In the area of Reporting, late submission of ORR-3 initial placement (IP) reports by the URM provider to the state has been a challenge. State is working with URM provider to develop a new protocol for ORR-3 IP reports to ensure state has adequate time to review and approve before submission to ORR, and to ensure compliance with ORR-required timeframes. |
D. |
Trends or Clarifications in Data |
Report any trends or clarifications in data submitted in Schedule E URM Program Data report around client caseload, new enrollments, outcomes for terminated clients, placements and capacity development. |
E. |
Monitoring / State Licensing Reviews |
Report any monitoring and/or state licensing reviews that occurred during the reporting period. |
E. 1. |
Monitoring Agency |
Indicate the name of the agency that monitored or reviewed the URM provider. |
E. 2. |
Date |
Indicate the date(s) of the monitoring and/or licensing review(s). |
E. 3. |
Purpose |
Indicate the purpose of the monitoring (e.g. regularly scheduled monitoring by SRC office, corrective action follow-up, annual state licensing review, etc.) |
E. 4. |
Corrective Actions Identified |
Indicate if any corrective action(s) were identified during the monitoring trip by entering “Yes” or “No.” Attach to Schedule E any monitoring reports from this reporting period that include corrective actions. Monitoring reports from the reporting period that did not include corrective actions do not need to be submitted to ORR. |
F. |
Optional: Client Success Story or Promising Practice |
Describe a success story of a URM client who received services during the reporting period; or, a promising practice that could be shared with other URM providers or states administering a URM program. If describing a success story, do not include any Personally Identifiable Information (e.g. client name, A #, country of origin, date of birth). |
ORR-6 Schedule F: Refugee Medical Assistance (RMA) and Medical Screening Back to top page Performance Report Instructions |
Schedule F is an annual report used to collect recipient and performance data related to benefits and services provided to clients of the Refugee Medical Assistance (RMA) and Medical Screening programs. Schedule F must be completed and submitted by states/grantees that operate an RMA and/or Medical Screening program(s). Schedule F is composed of four parts: Part I: Refugee Medical Assistance Recipients and Benefits; Part II: Medical Screening Recipients; Part III: Medical Screening Services; and Part IV: Data Explanations and Trends.
Note: Do not include any Personally Identifiable Information (PII) such as client name, Alien Number, country of
origin, and date of birth. Do not include any Personal Health Information (PHI) such as screening results connected to an individual; only report aggregate data.
General Information: Prior to completing Parts I-IV, enter the following information at the top of the report:
Item |
Data Element |
Instructions |
1. |
Annual Report, Fiscal Year |
Enter the Federal fiscal year represented in the annual report for the period October 1 – September 30. |
2. |
Date |
Enter the date the form is completed. |
3. |
State/Grantee |
Enter the name of the State, or name of grantee if not a State, that is providing the data. |
Part I: Refugee Medical Assistance Recipients and Benefits |
Sections A-C: Please fill out each section according to the provided instructions.
A. RMA Enrollment Caseload
Provide the breakdown of the total RMA enrollment caseload.
The caseload is capturing recipients enrolled in the RMA health coverage program.
Recipients who are getting a medical screening but who are not enrolled in the RMA health coverage program should not be counted.
Item |
Data Element |
Instructions |
A. 1.
|
Previous RMA recipients enrolled in this reporting period |
Enter the number of recipients who were reported as RMA recipients in the previous reporting period and who are enrolled in RMA during this reporting period, including
|
A. 2.
|
New RMA recipients enrolled during this reporting period |
Enter the number of recipients newly enrolled in RMA during this reporting period. |
A. 3. |
Total number of RMA recipients enrolled during this reporting period |
Once item 1 and 2 are completed, item 3 will auto calculate (total = 1 + 2).
|
B. RMA Termination Reason
Provide the breakdown of the total number of RMA terminations by the termination reasons listed below. A refugee is terminated from RMA when they are no longer enrolled in the RMA program.
Item |
Data Element |
Instructions |
B. 1. |
Reached 8 month time-eligibility |
Enter the number of recipients in this reporting period who reached the 8 month time-eligibility limit. |
B. 2. |
Transitioned to Medicaid |
Enter the number of recipients in this reporting period who became eligible for and transitioned to Medicaid before the end of the 8 month time-eligibility limit (e.g., SSI pending cases, recipients who become pregnant and qualify for Medicaid). |
B. 3. |
Out-Migrated |
Enter the number of recipients in this reporting period who out-migrated to a different state. |
B. 4. |
Other |
Enter the number of recipients in this reporting period who were terminated from the RMA program for any other reason. |
B. 5. |
Total Number of RMA Terminations |
Once item 1 through 4 are completed, item 5 will auto calculate (total = 1 + 2 + 3 + 4). |
RMA Recipient Use by Cost Range
Report RMA recipients’ healthcare-associated costs reimbursed in this reporting period by the cost ranges below.
The ranges are capturing the costs of recipients enrolled in the RMA health coverage program.
Include the costs of monthly premiums, if applicable, as well as additional claims/encounters.
If medical screening costs are billed through the RMA health coverage program as a covered benefit, include those costs here.
If medical screening costs are billed separately from the RMA health coverage program as an uncovered benefit, do not include those costs here.
Item |
Data Element |
Instructions |
C. 1. |
No costs incurred |
Enter the number of recipients enrolled in RMA who did not incur any costs in this reporting period. |
C. 2. |
$1 - $10,000 |
Enter the number of recipients enrolled in RMA who incurred a total cost between $1 and $10,000 in this reporting period. |
C. 3. |
$10,001 - $150,000 |
Enter the number of recipients enrolled in RMA who incurred a total cost between $10,001 and $150,000 in this reporting period. |
C. 4. |
$150,001 - $350,000 |
Enter the number of recipients enrolled in RMA who incurred a total cost between $150,001 and $350,000 in this reporting period. |
C. 5. |
Over $350,000 |
Enter the number of recipients enrolled in RMA who incurred a total cost over $350,000 in this reporting period. |
Part II: Medical Screening Recipients |
Sections A-E: Please fill out each section according to the provided instructions.
A. Timeliness of Medical Screenings
Provide the breakdown of the total number of medical screening recipients who completed a screening in this reporting period by the date ranges below.
Medical screening completion is defined as a recipient completing the screening services offered in a state’s approved State Plan or grantee’s approved plan if not a state.
Include primary and secondary refugee arrivals, URMs, and other ORR-eligible populations listed in Part II.D, including asylee derivatives.
“Days from arrival” means days from:
the date of arrival in the United States for refugees,
the date asylum was granted for asylees,
the date of certification for trafficking victims,
the date of eligibility for Cuban/Haitian entrants, as delineated in ORR PL 16-01 and its Documentation Guide and FAQ,
the date of eligibility for Afghans who arrived in the United States on or after July 31, 2021, as delineated in ORR PL 16-01, its Documentation Guide and FAQ, and ORR PL 22-02, and
the date of eligibility for other ORR-eligible populations, such as SIVs, survivors of torture, and Amerasians, as delineated in ORR PL 16-01, its Documentation Guide and FAQ, and ORR PL 22-02.
Item |
Data Element |
Instructions |
A. 1. |
Recipients who completed a screening within 30 days from arrival |
Enter the number of recipients completing screenings within 30 days from the date of arrival.
|
A. 2. |
Recipients who completed a screening within 31-90 days from arrival |
Enter the number of recipients completing screenings within 31-90 days from the date of arrival.
|
A. 3. |
Recipients who completed a screening beyond 90 days from arrival |
Enter the number of recipients completing screenings beyond 90 days from the date of arrival.
|
A. 4. |
Total recipients who completed a screening in this reporting period |
Once item 1 through 3 are completed, item 4 will auto calculate (total = 1 + 2 + 3). Generally, Part II.A.4 should total the number reported in Part II.C.3. |
B. Class A and Class B TB Cases Screening Completions
Provide the breakdown of the total number of Class A and Class B TB cases who completed a medical screening in this reporting period.
Medical screening completion is defined as a recipient completing the screening services offered in a state’s approved State Plan or grantee’s approved plan if not a state.
Include primary and secondary refugee arrivals and URMs as well as other populations eligible for refugee benefits reported in the Electronic Disease Notification System (EDN).
Item |
Data Element |
Instructions |
B. 1. |
Class A and Class B TB cases arrived |
Enter the number of recipients who arrived in the state with Class A and Class B TB conditions. |
B. 2. |
Class A and Class B TB cases who completed a screening |
Enter the number of recipients who arrived in the state with Class A and Class B TB conditions who completed a screening.
|
B. 3. |
Class A and Class B TB medical screening completion rate |
Once item 1 and 2 are completed, item 3 will auto calculate (completion rate = 2 divided by 1). |
C. Funding Source of Medical Screening Completions
Provide the breakdown of the total number of recipients who completed a medical screening in this reporting period by the categories below.
Medical screening completion is defined as a recipient completing the screening services offered in a state’s approved State Plan or grantee’s approved plan if not a state.
Include primary and secondary refugee arrivals, URMs as well as other populations eligible for refugee benefits listed in Part II.D, including asylee derivatives.
Do not include clients who initiated the screening but still have pending follow-up screening appointments.
Item |
Data Element |
Instructions |
C. 1. |
Recipients who completed a screening funded ONLY by CMA |
Enter the total number of recipients who completed medical screenings during the reporting period that were completely funded by Cash and Medical Assistance (CMA). For example, an adult refugee whose labs, medications, vaccinations, and physical exam were covered solely by CMA.
|
C. 2. |
Recipients who completed a screening partially funded by CMA |
Enter the total number of recipients who completed a medical screening during the reporting period that was partially funded by CMA. For example, a Medicaid-eligible adult refugee whose labs, medications, and vaccinations were covered by Medicaid but the physical exam was billed to CMA.
|
C. 3. |
Total recipients who completed a screening in this reporting period |
Enter the total number of recipients who completed a medical screening during the reporting period regardless of funding source. Depending on a state’s medical screening reimbursement model, Part II.C.1 and C.2 may not add up to C.3. Ideally, Part II.C.3 should generally total the number reported in Part II.A.4. |
D. Screening recipient completions by eligibility status
Provide the breakdown of the total number of recipients who completed a screening in this reporting period by eligibility status. The total of all eligibility types should equal the number of screening recipients reported in Part II.C.3.
Item |
Data Element |
Instructions |
D. 1. |
Refugee |
Enter the total number of refugees who completed a screening in this reporting period, including derivatives (V-93). |
D. 2. |
Asylee |
Enter the total number of asylees who completed a screening in this reporting period, including derivatives (V-92). |
D. 3. |
SIV (including SI/SQ Parolees and Conditional Permanent Residents) |
Enter the total number of Special Immigrant Visa (SIV) holders from Iraq and Afghanistan, Afghan SI/SQ Parolees, and Afghan Special Immigrant Conditional Permanent Residents who completed a screening in this reporting period. |
D. 4. |
Cuban/Haitian Entrant |
Enter the total number of Cuban/Haitian Entrants who completed a screening in this reporting period. |
D. 5 |
Afghan Humanitarian Parolee |
Enter the total number of Afghan Humanitarian Parolees (including Afghan unaccompanied minors) who completed a screening in this reporting period. |
D. 6. |
Other |
Enter the total number of other recipients (e.g., trafficking victims, Amerasians) who completed a screening in this reporting period. |
E. Screening recipient completions by age
Provide the breakdown of the total number of recipients who completed a screening in this reporting period by age group. The total (items 1 and 2) should equal the number of screening recipients reported in Part II.C.3.
Item |
Data Element |
Instructions |
E. 1. |
Child < 18 years |
Enter the total number of child recipients who completed a screening in this reporting period. A child is defined as someone who was younger than 18 years of age at the time of screening completion. |
E. 2. |
Adult ≥ 18 years |
Enter the total number of adult recipients who completed a screening in this reporting period. An adult is defined as someone who was 18 years or older at the time of screening completion. |
Part III: Medical Screening Services |
Sections A-L: Please fill out each section according to the provided instructions.
This part captures specific services for recipients who have completed a medical screening.
The data reported here should be a subset of the total number of medical screening completions reported in Part II.A.4 and/or Part II.C.3.
If there are no individuals in a given category, indicate zero.
Do not include any PII or PHI.
A. Lead Screening
Item |
Data Element |
Instructions |
A. 1. |
Children tested for lead (first test) |
Enter the number of children tested for lead; include only the first test (capillary or venous). |
B. Mental Health Screening
Item |
Data Element |
Instructions |
B. 1. |
Recipients provided a mental health screening |
Enter the number of recipients provided mental health screenings, including use of
|
a. |
Recipients referred for further evaluation or counseling |
Enter the number of recipients screened and referred for further evaluation and counseling with a mental health specialist (psychiatrist, psychologist, licensed clinical social worker, licensed professional counselor, etc.). Do not include primary care referrals. |
C. Parasite Screening
Provide the testing data for intestinal parasitic infections and malaria.
Item |
Data Element |
Instructions |
C. 1. |
Recipients who completed tests for parasitic infections |
Enter the number of recipients who completed tests for parasitic infections. Tests may include
|
D. Domestic Presumptive Treatment
Provide the following presumptive treatment data.
Presumptive treatment is defined here as either providing a prescription for a patient to fill or providing medications directly to the patient without testing, based on a review of their overseas medical records and risk factors per CDC guidelines. It does not necessarily mean tracking completion of the medication regimen.
Item |
Data Element |
Instructions |
D. 1. |
Recipients presumptively treated |
Enter the number of recipients presumptively treated by the screening clinic. Part III.D.1 sub-items a–d may not add up to Part III.D.1 due to multiple presumptive treatments. |
a. |
Recipients presumptively treated for strongyloidiasis |
Enter the number of recipients presumptively treated by the screening clinic for strongyloidiasis. |
b. |
Recipients presumptively treated for schistosomiasis |
Enter the number of recipients presumptively treated by the screening clinic for schistosomiasis. |
c. |
Recipients presumptively treated for soil-transmitted helminths |
Enter the number of recipients presumptively treated by the screening clinic for soil-transmitted helminths (e.g., hookworm, Ascaris, whipworm/trichuriasis). |
d. |
Recipients presumptively treated for malaria |
Enter the number of recipients presumptively treated by the screening clinic treated for malaria. |
E. HIV Screening
Item |
Data Element |
Instructions |
E. 1. |
Recipients tested for HIV |
Enter the number of recipients tested for HIV, including
|
F. Tuberculosis (TB) Screening
Item |
Data Element |
Instructions |
F. 1. |
Recipients who completed a TST |
Enter the number of recipients who completed a tuberculin skin test (TST). Completion is defined as having the skin test reaction read within 48–72 hours of administration. |
F. 2. |
Recipients tested with IGRA |
Enter the number of recipients provided an Interferon-Gamma Release Assay (IGRA) blood test. QuantiFERON-TB Gold and T-SPOT.TB are approved IGRA tests. |
G. Hepatitis B Screening
Item |
Data Element |
Instructions |
G. 1. |
Recipients tested for hepatitis B (surface antigen) |
Enter the number of recipients tested for hepatitis B with the hepatitis B surface antigen test. |
H. Hepatitis C Screening
Item |
Data Element |
Instructions |
H. 1. |
Recipients tested for hepatitis C (HCV antibody test) |
Enter the number of recipients tested for hepatitis C with the HCV antibody test. |
I. Syphilis Screening
Item |
Data Element |
Instructions |
I. 1. |
Recipients tested for syphilis (VDRL/RPR) |
Enter the number of recipients tested for syphilis with the by VDRL/RPR test.
|
J. Chlamydia Screening
Item |
Data Element |
Instructions |
J. 1. |
Recipients tested for chlamydia |
Enter the number of recipients tested for chlamydia.
|
K. Gonorrhea Screening
Item |
Data Element |
Instructions |
K. 1. |
Recipients tested for gonorrhea |
Enter the number of recipients tested for gonorrhea. |
L. Primary Care Referrals
Item |
Data Element |
Instructions |
L. 1. |
Recipients referred to primary care
|
Enter the number of recipients who completed a screening and were referred to primary care, including
Referral is defined here as active (e.g., making the appointment for the refugee) or passive (e.g., simply providing the refugee with referral options). NOTE: Primary care specialties are pediatrics, internal medicine, and family medicine. |
Part IV: Data Explanations and Trends |
Sections A-B: Please fill out each section according to the provided instructions.
A. Explain anomalies in Parts I, II, and III
Explain any data anomalies reported in Parts I–III (e.g., missing data due to reporting issues, numbers that do not add up the way they are expected to, or significant increases or decreases in numbers).
B. Report Emerging Health Trends
Report any emerging health trends (e.g., new cases of certain health conditions).
THE PAPERWORK REDUCTION ACT OF 1995 (Public Law 104-13)
Public reporting burden for this collection of information is estimated to average fifteen hours 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.
1 For more information regarding populations eligible for ORR benefits and services, including the URM program, see 45 C.F.R. § 400.43, ORR Policy Letter (PL) 16-01, its Documentation Guide, FAQ, and ORR PL 22-02.
2 For more information regarding populations eligible for the URM program, see section 1.1 of the URM Program Policy Guide, ORR Policy Letter (PL) 16-01, its Documentation Guide, FAQ, and ORR PL 22-02.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2022-01-25 |