1 URM Program Application Form

OMB Control No.: 0970-0550

Expires: XX/XX/XXXX

Paperwork Reduction Act

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to collect information on an unaccompanied minor interested in participating in the Unaccompanied Refugee Minors Program. Public reporting burden for this collection of information is estimated to average 1.5 hours per grantee, 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 (8 U.S.C. 1522(d)). 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. The OMB # is 0970-0550 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly in the Office of Refugee Resettlement at [email protected].

UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM APPLICATION

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INSTRUCTIONS

As you complete this URM application, please remember the following:

• There is an online policy guide for the URM program which includes policy on which minors are eligible for URM. Please review the policy guide prior to submitting a URM application: https://www.acf.hhs.gov/orr/policy-guidance/orr-guide-eligibility-placement-and-services-unaccompanied-refugee-minors-urm-0.

• There is also an about page for the URM program which provides details on services provided in the URM program and locations of URM programs across the country: https://www.acf.hhs.gov/orr/programs/refugees/urm.

• There are resources available on RADS to help you complete the application. To access these resources, please go to “General Help” at the bottom of the screen and then click on “Training Resources.”

• Some of the questions in the application form will prompt you to upload a document. There will be a screen for document upload available after you answer all of the questions in the form. Additionally, after submission, you will be able to upload any additional documentation by going to the “Documents” tab on the submitted application.

• The ORR/URM team will review the application to determine if the child is eligible for URM and can be referred out for placement. Please be aware that even if a child is determined to be eligible for URM and referred out for a placement, URM placement is not guaranteed.

• For any general questions about eligibility for URM or how to complete a URM application, please email the ORR/URM team at [email protected].

• Once the application is submitted, the best way to ask questions about the application is to post a comment to the application. All submitted applications have a “Comments” tab at the top. The ORR/URM team prefers to communicate via the Comments section instead of through emails. If a URM team member posts a comment on an application, you will receive an email notification stating that a new comment has been added to the application. Please log in to RADS promptly to review and respond to the comment that was added.

SECTION 1: ASSISTER INFORMATION

Complete the following if you are assisting a minor with this application

First Name(s):

Last Name(s):

Titles(s):

Agency Name:

Agency Address:

City:

State:

Zip:

Phone Number:

Email:

Relationship to minor:

Attorney

Authorized Representative

Case Manager

Other (please describe):

In the event that the assister cannot be reached, please provide the name, phone number, and email address for a back-up point of contact:

Back-up contact name: *

Back-up contact phone number: *

Back-up contact email address: *

SECTION 2: MINOR’S CONSENT

Please ensure you explain the URM program to the minor, including the placements and services available in the URM program. If the minor is 12 years of age or older, please complete the consent form below. If the minor is 11 years of age or younger, the minor should not sign the form, however, please still provide assister signature on the form and discuss the URM program with the minor before submitting the application. ORR/URM will reach out after application submission for an alternative consent process for children 11 years of age or younger.

After Section 1 and Section 3 of the URM application are fully filled in, you will see a button in the top right that says, “Print Signature Form.” You will be required to upload the signed signature page at the end of the application submission process, so please remember to print out the form.

ORR/URM requires actual signatures on the form; typed names are not acceptable.

I know what the Unaccompanied Refugee Minors (URM) program is. I know the placements and services the URM program has. I know that I might be eligible for the URM program. I agree to my application being submitted to the URM program. ORR will determine if I am eligible. ORR will communicate with the adults I work with about my URM application. ORR will tell them if I am eligible. ORR will tell them if a URM placement is found for me. I am signing below to show I understand.

Signature of Minor:

Signature of Assister:

SECTION 3: MINOR’S BIOGRAPHICAL INFORMATION

First Name:*

Middle Name:

Last Name: *

All Other Names Used:

Gender: *

Female

Male

X (unspecified, another)

Country of Birth:

Date of Birth (mm/dd/yyyy): *

Age:

HHS Tracking Number (this is only applicable to minors who have received an OTIP eligibility letter; the HHS tracking number can be found on the minor’s OTIP eligibility letter): *

Alien Number (Note: You will be required to upload a document that confirms the minor’s A# at the end of the application submission process). *

English Proficiency: *

Conversational

Requires an Interpreter

Tested Proficient

Marital Status: *

Single

Married

Divorced

Primary Language:

Is this minor currently in ORR custody? *

Yes

No

If yes, provide the date the minor first entered ORR custody (mm/dd/yyyy): *

Select each document used to verify the age and identity of minor (Note: You will be required to upload this document(s) at the end of the application submission process.):

Birth Certificate

Forensic Dental Scan

DOJ/DHS Immigration Doc

Bone Density Scan

UNHCR BID Report

Other (please describe)

Does the minor have any children? : *

Yes

No

If yes, are any of the minor’s children currently with them? *

Yes

No

If the minor has any children (with them or not), please provide the name(s), date(s) of birth, current location(s), and birthplace(s) of each child. Additionally, for any children who are currently with the minor, please upload the child’s birth certificate at the end of application submission: *

Eligibility Type * Verification Documents(s)—(Note: You will be required to upload this document(s) at the end of the application submission process) *

Refugee	I-94	Other
Asylee	Asylee Letter	I-94	Other
Cuban/Haitian Entrant	I-862	I-94	Other
Victim of Human Trafficking	Eligibility Letter	T-visa	Other
Special Immigrant Juvenile	I-360 Approval Notice	I-485 Approval Notice	Other
U Status Recipient	U-Visa	I-797	Other
Afghan Humanitarian Parolee	I-94	Foreign passport with required stamp	Other
Ukrainian Humanitarian Parolee	I-94	Foreign passport with required stamp	Other
Other	Other

Eligibility Type Other (Please describe):

If “Other” is selected as a Verification Document, please describe document(s) below:

Are there any discrepancies in the minor’s age, date of birth, A#, or spelling of their name across documents? *

Yes

No

If yes, please explain:

Does the minor have any relatives who also have a pending URM application? *

Yes

No

Unsure

Does the minor have any relatives who are already in the URM program? *

Yes

No

Unsure

Does the minor have any relatives in ORR custody who are not currently eligible for the URM program? *

Yes

No

Unsure

SECTION 4: PLACEMENT INFORMATION

Current Placement

Current caregiver:

Current placement city: *

Current placement state: *

For minors in ORR custody, please provide the date the minor entered their current placement (mm/dd/yyyy):

For minors not in ORR custody, please describe why continuing with their current caregiver is not possible or is not in the minor’s best interest:

Current Placement Type: *

Basic Foster Home

Influx or Other Emergency Intake Facility

Regular Group Home

Relative

Residential Treatment Center

Secure Care

Shelter Care

Sponsor (non-relative)

Staff Secure

Therapeutic Foster Home

Therapeutic Group Home

Other

Please provide more details on the minor’s current placement arrangement (for example, size of placement, school arrangements, etc.) *

For minors in ORR custody, is the minor in care at a UC program that has a co-located URM program operated by the same agency? *

Yes

No

If yes, is the co-located URM program planning to place this minor, if approved (AKA, is this case ‘straight assured’)? *

Yes

No

If yes, please upload a placement assurance memo immediately after submitting this application. The placement memo should:

• Describe the placement.

• Provide sufficient information for ORR to verify that the placement being offered is a URM placement with the same agency. For example, include a name, location, and/or other information which demonstrates that the recommendation and offered placement are the same, or that a new placement has been identified.

• Include a point of contact (including title) with authority to determine placements within the agency.

• Provide any details necessary to ensure that legal responsibility can be established.

Preferred/Recommended Placement in URM:

Below are questions related to the minor’s preferences for placement within the URM program; this is followed by a section with questions about the minor’s current provider’s recommendations. It is okay for the current provider’s recommendations to differ from the minor’s preferences. Please note that the URM program only exists in a limited number of states. The list of locations is available on the ORR website: https://www.acf.hhs.gov/orr/programs/refugees/urm. Be aware that not all placement types are available in each location.

Minor’s Preferences

If the minor is found eligible for URM and referred out for placement, ORR will try to honor a minor’s preferences, when possible. However, ORR cannot guarantee a specific placement. Please encourage minors to keep an open mind to a variety of placements.

What are the minor’s preferences for a placement type within the URM program? *

NOTE: If the minor is open to any placement type, please select all.

Foster Home

Group Home

Semi-Independent Living

Other

If other, please describe:

Please describe the reason the minor prefers these placement types:*

Please describe any other preferences the minor has for placements within the URM program and reasons for this preference. Please encourage minors to keep an open mind to all placements and ensure you are not discussing placements with the minor in a state where the URM program does not exist.

Current Provider Recommendations

What is the minor’s current provider’s recommendations for appropriate placement types for this minor within the URM program? *

Basic Foster Home

Therapeutic Foster Home

Regular Group Home

Therapeutic Group Home

Semi-Independent Living

Other

If other, please describe:

Please describe the reason for this recommendation. If you recommend the minor enter a therapeutic placement, please specify the therapeutic supports you feel the minor needs to receive. If you recommend a semi-independent living placement, please describe the minor’s current independent living skills. *

Please provide any other recommendations/considerations that the current provider has for the placement location or other characteristics of a potential URM placement.

SECTION 4.1: CUSTODY INFORMATION

Yes

No

Does an entity or individual in the U.S., other than ORR, have legal responsibility for the minor? *

If yes, please explain and upload a copy of the relevant court order, such as a dependency order, letters of guardianship/conservatorship, etc. at the end of application submission:

Are there known barriers which could prevent or delay a state's ability to arrange legal responsibility for the minor? *

Yes

No

If yes, please describe:

Is there state or local court hearing (related to custody/dependency) pending for this applicant? Please do not include immigration court or Master Calendar Hearing appointments, as this is asked in Section 4.6. *

Yes

No

If yes, please explain (provide date, type, and city/state) and upload a copy of the hearing notice, if available, at the end of application submission:

Yes

No

Is there a dependency or SIJ findings order for this minor? *

If yes, please indicate the date and court of jurisdiction and upload a copy of the order at the end of application submission:

Are there any other court proceedings that have occurred for this minor, either for the purposes of starting to establish legal responsibility or for filing for SIJ? *

Yes

No

If yes, please explain and upload a copy of any additional court documents available at the end of application submission.

SECTION 4.2: FAMILY REUNIFICATION/SPONSOR INFORMATION

Below are questions related to the minor’s biological mother, biological father, other legal guardians, and other adult relatives or possible sponsors in the United States. If any of the information in this section of the application changes after you submit the application, please notify the ORR/URM team immediately by posting a comment on the submitted application. In particular, if the minor’s biological mother, biological father, or other legal guardians arrive in the United States sometime after this application is submitted, please immediately notify the ORR/URM team by posting a comment on the application.

Mother

Is the minor’s biological mother currently residing within the United States? *

Yes

No

Unknown

If yes, please provide the following information in the text box below:

• Mother’s name

• Date of last contact with the mother

• If/when the mother was last assessed for reunification with the minor

• The reason(s) the minor’s mother is unable/unwilling/unsuitable to care for the minor

• Whether the minor wishes to reunify with the mother

• Whether a home study was conducted. If yes, please upload the report at the end of application submission.

• For minors in ORR custody, whether the mother was formally denied as a sponsor. If yes, please provide the denial date and upload a copy of the denial letter at the end of application submission.

If no or unknown, please provide the mother’s name, current location or the last known location, and date of last contact with the minor’s mother:

Father

Is the minor’s biological father currently residing within the United States? *

Yes

No

Unknown

If yes, please provide the following information in the text box below:

• Father’s name

• Date of last contact with the father

• If/when the father was last assessed for reunification with the minor

• The reason(s) the minor’s father is unable/unwilling/unsuitable to care for the minor

• Whether the minor wishes to reunify with the father

• Whether a home study was conducted. If yes, please upload the report at the end of application submission.

• For minors in ORR custody, whether the father was formally denied as a sponsor. If yes, please provide the denial date and upload a copy of the denial at the end of application submission.

If no or unknown, please provide the father’s name, current location or the last known location, and date of last contact with the minor’s father: *

Other Legal Guardian(s)

Does the minor have any other legal guardians?

Yes

No

Unknown

If yes, please provide the name(s), current location(s) or last known location(s), and date(s) of last contact. If the minor has any legal guardians in the United States, please provide all of the same information that is asked for above for biological mothers or biological fathers who are in the United States.:

Other Sponsors

Does the minor have any other adult relatives or unrelated sponsors living in the United States, even if these individuals have been determined to be unable/unwilling/unsuitable to care for the minor?

Note: Please answer yes even if the relative/sponsor was ruled out while the minor was in a previous placement. *

Yes

No

If yes, please provide details on all adult relatives or sponsors, including relationship to the minor, location in the United States, and evidence, if any, that the adult is unwilling/unable/unsuitable to care for the minor.

SECTION 4.3: BEHAVIORAL HEALTH INFORMATION

Does the minor's placement history include incident reports, such as ORR's Significant Incident Reports (SIRs), even if these SIRs occurred at a previous placement? *

Yes

No

If yes, please explain and upload the reports at the end of application submission. Note for minors in ORR custody, SIRs are needed from the minor’s entire time in ORR care, including from previous placements. For SIRs with addendums, only the final addended version of the SIR is needed. If there are multiple SIRs, it is preferred that SIRs are uploaded in one PDF in chronological order, if possible.

Does the minor have any criminal history in the United States or prior to arriving in the United States?*

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Does the minor have a history of substance use? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Is the minor a danger to themselves or others, as determined by a clinician or other qualified evaluator? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Does the minor have a history of being destructive with property? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Are there any other safety or security risks? *

Yes

No

If yes, please explain and provide recommendations for safety planning. If the minor is on a safety plan, please upload the plan at the end of application submission:

SECTION 4.4: PHYSICAL HEALTH AND MENTAL HEALTH INFORMATION

Does the minor have a history of receiving mental health services? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Does the minor have a diagnosis for a mental health condition? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

Has the minor been hospitalized or received residential treatment for a mental health reason? *

Yes

No

If yes, please explain and upload documentation at the end of application submission, if available:

From your experience working with the minor and case documentation, please summarize the minor’s history of significant trauma and/or impactful life events: *

Does the minor take prescription medication for physical or mental health issues? *

Yes

No

If yes, please explain:

Does the minor have any physical health needs? *

Yes

No

If yes, please explain:

Does the minor require accommodations for a disability? *

Yes

No

If yes, please explain:

SECTION 4.5 EDUCATIONAL AND EMPLOYMENT INFORMATION

Is the minor currently enrolled in an educational program? *

Yes

No

If no, please explain:

Does the minor need any educational accommodations or have an individualized education plan (IEP)?

Yes

No

If yes, please describe needed accommodations and upload the most current IEP at the end of application submission, if available:

What is the highest educational level completed by the minor?

Please describe the minor's educational goals:

Please describe the minor's employment goals:

Is the minor currently authorized to work in the United States? If yes, please upload the minor’s Employment Authorization Document (EAD) at the end of application submission*

Yes

No

SECTION 4.6: IMMIGRATION INFORMATION

Does the minor have an attorney of record or an accredited representative? *

Yes

No

If yes, please provide the name and contact information, if not the same as the assister information provided in section 1 of this application:

Does the minor have a Child Advocate? *

Yes

No

If yes, please provide the name and contact information, if not the same as the assister information provided in section 1 of this application:

Is there a pending immigration hearing relevant to this applicant? *

Yes

No

If yes, please explain (provide date, type, and city/state) and upload a copy of the hearing notice at the end of application submission, if available:

SECTION 4.7: ADDITIONAL COMMENTS OR INFORMATION

Please provide a strengths-based summary of the minor, such as their accomplishments, interests, and overall life goals. *

Please use this space to provide any additional comments or information:

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REQUIRED DOCUMENTATION

Note: Below are some of the critical documents needed for a URM application. Please upload all the documents asked for below. If your answers to questions on the application indicated that you need to upload any additional documents beyond the ones that are below, please do so by submitting the application and then going to the Document upload screen on the submitted application.

Signature Page: This is an auto generated document that you need to print by hitting the “Print Signature Page” button at the top of the page. It requires the minor’s AND assister’s signatures, unless the minor is under age 12: *

Choose file

Age/Identity Verification document This should be from the minor’s country of origin, such as a birth certificate. See URM policy for a list of acceptable age and identity documents: https://www.acf.hhs.gov/orr/policy-guidance/orr-guide-eligibility-placement-and-services-unaccompanied-refugee-minors-urm#1.4.1: *

Choose file

Alien Number Verification document: Such as a Notice to Appear or another document issued by Department of Homeland Security that includes the minor’s name and A#. Documents issued by ORR do not serve as proof of a minor’s A#. If you do not have any documents issued by DHS that can serve as proof, please email [email protected] for technical assistance:*

Choose file

Eligibility Verification document: These are dependent on eligibility type, such as an OTIP letter, I-94, approved I-360 form and dependency documents, etc. See URM policy for a list of which documents are acceptable for each eligibility category: https://www.acf.hhs.gov/orr/policy-guidance/orr-guide-eligibility-placement-and-services-unaccompanied-refugee-minors-urm#1.1 *

Choose file

(Other document upload fields are generated based on responses to questions on the applications)