ORR-3 URM Placement Report

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

ORR-3 Report Form_rev.xlsx

OMB: 0970-0034

Document [xlsx]
Download: xlsx | pdf
DEPARTMENT OF HEALTH AND HUMAN SERVICES












OMB No. 0970-0034
Office of Refugee Resettlement












Exp. XX/XX/XXXX












































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


First


Middle





























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

















State/URD Agency
Provider Agency

















Agency Name:


Agency Name:
Address:


Address:

City:

City:
State:
Zip:

State:
Zip:

















National Voluntary Agency

USCCB
LIRS
Not Applicable


















Section I: Report Action


1. Initial Placement - Must be submitted within 30 days of placement

2. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change




















Transfer to/from another URM Program









Date of Action (mm/dd/yyyy)





Transfer to


Transfer from



























State Agency:















Provider Agency:






























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












Became a parent













Change in biological parent's location












Change in immigration data












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















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














Establishment of or change in legal responsibility






























Explain "Change of Status".



































3. Termination: Date of Termination:




















Reunified with parents






Not compliant with State/Program requirement(s)







Unified with relatives






Ran away







Adopted






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







Became a U.S. Citizen






Immigration detention







Emancipated






Incarcerated







Concluded ORR-funded services/benefits






Deceased







Left program voluntarily






Other























Explain destination/current situation at case closure.























































































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















URM Placement
Services/Benefits only





































Section II: Identifying/ Basic Data

















1. Gender: 2. Date of Birth


3. Date of Eligibility


4. Date of Initial Placement









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


















7. Eligibility Type:


Refugee

Asylee
C/H Entrant

U-Status Recipient


Ukrainian Humanitarian Parolee




Special Immigrant Juvenile (SIJ)



Afghan Humanitarian Parolee



Trafficking Victim

Other:



































8. Caseworker/Provider Assessment on Personal Functioning of the Youth (complete at initial placement only):
Assess the youth's functioning in the following areas at an age-appropriate level on a scale of 1 through 5, as indicated below. Provide an explanation if necessary.









Poor Below Average Average Above Average Excellent Explain
English Language Skill




Education (other than English)




Health Condition



Mental Health



























































9. URM's Children in Care:













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

1st child













2nd child













3rd child































10. Mother of URM:
Last:
First:
Middle:
a. Living: b. Mother's address when minor arrived in U.S.:

Yes

No c. Current Address:

Unknown
Same as b. above










11. Father of URM:
Last:
First:
Middle:
a. Living: b. Father's address when minor arrived in U.S.:

Yes

No c. Current Address:

Unknown
Same as b. above

















Section III: Immigration

















1. Immigration
















Refugee







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






Asylee






U-Status Recipient






SIJ (I-360 approval)







T-Status Recipient






Afghan Humanitarian Parolee







Lawful Permanent Resident






Cuban/Haitian Entrant-No immigration status







Other:






Ukrainian Humanitarian Parolee














2. Youth is receiving immigration assistance.







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

Yes
No





















3. Youth has work authorization/Employment Authorization Document.
















Yes
No





























Section IV: Placement



























1. Placement Type:


2. Placement Cost:




(daily rate)

Foster Family Home











Therapeutic Foster Home











Group Home















Supervised Independent Living















Residential Treatment















Long-term hospitalization (more than 2 weeks)















Absent from program but legal responsibility retained















Living independently but receiving ORR-funded services/benefits















Other:































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


Name:


Same as URM Provider





Relation of caregiver:




Placement via Subcontract





Address:










City:



State:
Zip:






















Section V: Legal Responsibility















1. Legal responsibility has been petitioned.

















Yes, it was petitioned within 30 days of enrollment.






Date:







Yes, it was petitioned past 30 days of enrollment.






Date:







No, it hasn't been petitioned.






























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

















Yes
Date:




No
Pending




















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

















Yes
Date:




No N/A



















3. Court name with jurisdiction:
































4. Agency name to whom legal responsibility assigned:











Same as URM Provider



































5. Legal responsibility has ended. Date Ended

Yes
No


















Section VI: Report Submission Authority















1. Provider Agency
































1. Provider Name















Address















City
State


Zip Code


















User Name: Title: Agency Approval Date:


(mm/dd/yyyy)
Phone:
Email:

















Secondary contact: Title:







Phone:
Email:


































2. State/URD Agency
































Agency Name














Address














City
State


Zip Code


















User Name: Title: Agency Approval Date:


(mm/dd/yyyy)
Phone:
Email:

















3. ORR















Name: Title: ORR Approval Date:


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














































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