OMB 0970-0554 [valid through MM/DD/20YY]
Office of Refugee Resettlement
Notice of Placement in a Restrictive Setting
You are in the custody of the Office of Refugee Resettlement (ORR), and have been placed in a restrictive setting (a secure or staff secure facility, or a residential treatment center) for the reasons listed below. If you have any questions about this placement, please discuss them with your case manager, your attorney, or an ORR-funded legal service provider.
Section
A: UC Information
UC Full Name A# (no spaces)
Country of Birth Preferred Language
Care Provider Name Type of Facility
Out-of-Network Facility Name (if applicable)
Date of Placement at Current Restrictive Facility
Date of Initial Notice of Placement
Date Next Notice of Placement is Due (within 30 days)
Section
B: ORR's Determinations Related to Safety
UC presents a danger to self or community
UC poses a risk of escape
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
document and
inform
UC
of
the
reason
they
have
been
placed
in
a
restrictive
setting.
Public
reporting
burden
for
this
collection
of
information
is
estimated
to
average
0.33 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
(Flores
v.
Reno
Settlement
Agreement,
No.
CV85-4544-RJK
(C.D.
Cal.
1996)).
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].
| Version 5 Page 1 of 4
Revised. MM/DD/2022
For each type of placement, check all reasons that apply for that placement only. Do not check reasons listed under a type of placement that is not applicable to the current facility.
ORR has determined that you pose a danger to self or others; or have been charged with having committed a criminal offense. ORR considered that you:
Are charged with a crime, are chargeable with a crime, or have been convicted of a crime; or are the subject of delinquency proceedings, have been adjudicated delinquent, or are chargeable with a delinquent act1
Have committed, or have made credible threats to commit a violent or malicious act while in ORR custody
Have engaged in conduct that has proven to be unacceptably disruptive of the normal functioning of a staff secure facility in which you were placed such that transfer may be necessary to ensure your welfare or the welfare of others
Have self-disclosed violent criminal history prior to placement in ORR custody that requires further assessment
Have committed sexual abuse2, where there is coercion by overt or implied threats of violence against another person and/ or there is an immediate danger to others
Are pending transfer or discharge/release to: (no other option above should be checked)
ORR has determined that you have a serious psychiatric or psychological issue that cannot be addressed in an outpatient setting and you are a danger to self or others. A licensed psychologist or psychiatrist has indicated that you:
Have not shown reasonable progress in the alleviation of your mental health symptoms after a significant period of time in outpatient treatment.
Demonstrate behavior that is a result of your underlying mental health symptoms and/or diagnosis and cannot be managed in an outpatient setting;
Require therapeutic-based intensive supervision as a result of mental health symptoms and/or diagnosis that prevent you from independent participation in the daily schedule of activities;
Present a continued and real risk of harm to self, others, or the community, despite the implementation of short-term clinical interventions.
Are pending transfer or discharge/release to: (no other option above should be checked)
ORR has determined that you require close supervision, but do not require placement in a secure care provider facility. ORR considers that you:
Have been unacceptably disruptive to the normal functioning of a shelter care facility such that transfer is necessary to ensure the welfare of others
Are an escape risk
Have displayed a pattern of severity of behavior, either prior to entering ORR custody or while in ORR care, that requires an increase in supervision by trained staff
Have non-violent criminal or delinquent history not warranting placement in a secure care provider facility, such as isolated or petty offenses
Are pending transfer or discharge/release to: (no other option above should be checked)
Case Manager Notes
Case Coordinator Notes
Name Recommendation
Federal Field Specialist Notes
Name ORR Overall Recommendation
Section E: Your Rights to Challenge Your Placement
ORR will review your placement, at a minimum, every 30 days to determine whether your placement in a restrictive level of care is still necessary.
You have the right to consult an attorney and/or a child advocate to assist you. This Notice of Placement will be provided to your attorney and/or child advocate automatically.
The Notice of Placement will also be provided to your parent or legal guardian, unless they cannot be reached, there is an important
reason not to share it with them for your own welfare, or you are age 14 years or older and you request they not receive it.
At any time after you receive this Notice of Placement, there are three ways you may request that ORR reconsider your placement in a restrictive setting:
You may request a Placement Review Panel to reconsider your placement.
You may ask a Federal District Court to review your case.
You may request a bond hearing from an Immigration Judge to decide whether you are a danger to the community. However, the bond hearing outcome does not automatically change your placement.3
For more information on this process, please ask your case manager, attorney, or child advocate.
Section
F: Acknowledgement and Certification
UC's Signature/Mark Date
Please check this box ONLY if the child refused to sign the Notice of Placement.
Care Provider/Issuing Official's Signature Date
Care Provider/Issuing Official's Name and Title
This document was explained to the UC in
by , ID#
Excluding: isolated offenses that (1) were not within a pattern or practice of criminal activity and (2) did not involve violence against a person, or the use or carrying of a weapon (e.g., breaking and entering, vandalism, DUI, etc.); or petty offenses which are not considered grounds for a stricter means of detention in any case (e.g., shoplifting, joy riding, disturbing the peace, status offenses).
As defined by the Interim Final Rule on Preventing, Detecting, and Responding to Sexual Abuse, 45 CFR Part 411 and in UC Policy Guide Section 4.1.1 Sexual Abuse.
An immigration judge does not rule on any of the following: release to a sponsor; the unaccompanied child's placement or conditions of placement while in ORR custody; or releasing the child on his or her own recognizance (see UC Policy Guide Section
2.9 Bond Hearings for Unaccompanied Children).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Title | Sponsor Check Request Form |
Author | Shannon Herboldsheimer |
File Modified | 0000-00-00 |
File Created | 2023-08-31 |