Office of Refugee Resettlement Waiver Request Form

Generic for ACF Program Monitoring Activities

Waiver Request Form__06252021

Office of Refugee Resettlement Waiver Request Form

OMB: 0970-0558

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ORR WAIVER REQUEST FORM

VERSION 1.0 (LAST UPDATED: JUNE 25, 2021)

Shape2

GRANTEE/CONTRACTOR SECTION – TO BE COMPLETED BY THE REQUESTOR

Name of Facility/Provider:

Primary Point of Contact (POC) Name:


Address of Facility/Provider:

POC Phone No and Email:


Type of Facility/Provider:

POC Title:


WAIVER REQUEST #1

☐Initial Request Renewal Request

Date of Initial Request _______

Date of Renewal(s) _______; _______; ______

Requested Timeframe of Waiver:

Specific waiver being requested:


Why is the waiver needed (Specific provision unable to meet and why):


What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?


WAIVER REQUEST #2

☐ Initial Request Renewal Request

Date of Initial Request _______

Date of Renewal(s) _______; _______; ______

Requested Timeframe of Waiver:

Specific waiver being requested:

Why is the waiver needed (Specific provision unable to meet and why):


What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?


WAIVER REQUEST #3

☐ Initial Request Renewal Request

Date of Initial Request _______

Date of Renewal(s) _______; _______; ______

Requested Timeframe of Waiver:

Specific waiver being requested:

Why is the waiver needed (Specific provision unable to meet and why):


What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?


OFFICE OF REFUGEE RESETTLEMENT (ORR) SECTION – TO BE COMPLETED BY APPROVER

WAIVER REQUEST #1

☐ Approved


Denied

Approved with conditions:

WAIVER REQUEST #2

☐ Approved


Denied

Approved with conditions:

WAIVER REQUEST #3

☐ Approved


Denied

Approved with conditions:

PLAN OF SUPERVISION/TRAINING

Select if a plan of supervision or training is attached to this form




File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorGrippi, Amy (ACF)
File Modified0000-00-00
File Created2023-07-29

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