URM ORR-3 and ORR-4 Report Forms

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Refugee Resettlement

OMB No. 0970-0034
Exp. XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information
collection, the Administration for Children and Families (ACF) is gathering data on youth served through the Unaccompanied
Refugee Minors Program including their location, status, and progress. Public reporting burden for this collection of information is
estimated to average .5 hours for respondents from state agencies, 1 hour for respondents from provider agencies, and .5 hours
for youth participants, 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 Office of Management and Budget (OMB) control number. The OMB # is 0970-0034
and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly
at [email protected].

Name of Youth
Last

Alien Registration No.

First

HHS Tracking No.

Middle

ORR-4 REPORT FORM
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM
OUTCOMES REPORT
State/ URD Agency
Agency Name:
Address:
City:
State:

Provider Agency
Agency Name:
Address:
City:
State:

Zip:

Zip:

Section I: Report Action
1. Annual Outcomes Report
2. Follow-up Annual Report: Former URM clients who are 17 to 21 years old and have terminated all ORR-funded services. Proceed to
Section VI. Outcomes.
Date data was collected

(mm/dd/yyyy)

Age
Section II: Identifying Data
1. Date of Birth

2. Gender

Female

Male

X

Section III: Education and Personal Functioning of the Youth
1. Education Information:
a. Most Recent Education and Grade Level, if applicable
Regular Mainstream School
Less than 6th grade
6th grade
7th grade
8th grade
9th grade
10th grade
11th grade
12th grade

Alternative to High School
9th grade
10th grade
11th grade
12th grade
Dual-credit program
No Grade Assigned
GED program
Trade/Vocational program
Job Corps/Job Corps equivalent
Post-secondary education
Not in school

Provide additional information.

b. Youth is receiving English Language Learner (ELL) support.

No

Yes

2. Caseworker/Provider Assessment:
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

English Language Skill
Education (other than English)
Social Adjustment
Health Condition
Mental Health
Preservation of Ethnic and Religious Heritage
Readiness to Live Independently

Below
Above
Average
Excellent
Average
Average

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Page 1 of 3

Explain

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Refugee Resettlement

OMB No. 0970-0034
Exp. XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information
collection, the Administration for Children and Families (ACF) is gathering data on youth served through the Unaccompanied
Refugee Minors Program including their location, status, and progress. Public reporting burden for this collection of information is
estimated to average .5 hours for respondents from state agencies, 1 hour for respondents from provider agencies, and .5 hours
for youth participants, 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 Office of Management and Budget (OMB) control number. The OMB # is 0970-0034
and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly
at [email protected].

Name of Youth
Last

First

Alien Registration No.

HHS Tracking No.

Middle

Section IV: Family Reunification
Yes

1. The youth has a permanency plan.

No

a. The youth's most recent primary permanency goal was:
Adoption
Guardianship
Another Planned Permanent Living Arrangement (APPLA)
Permanent Placement with Fit and Willing Relative (PPFWR)

Reunification

2. Family reunification efforts in the reporting period
a. Parents or relatives in the U.S. have been (re-)assessed for reunification.

Yes

No

b. There have been significant developments in reunification efforts.
If Yes, describe efforts and significant developments:

Yes

No

c. There has been a decision to not reunify the youth with a parent or relative.

Yes

No

If Yes, explain any such decisions; include relationship(s) and reason(s) for not reunifying youth.

3. There have been family tracing efforts with parents or relatives in other countries for the purpose of reunification.
Yes
No
If Yes, describe family tracing efforts.

Section V: Transition to Adulthood Services
1. Youth's residence:
Address:
City:

State:

Zip:

2. Service Type(s):

Yes

No

a. Youth remains in foster care
b. Post-adjudication juvenile probation
c. Special education
d. Independent living needs assessment
e. Academic support
f. Post-secondary educational support
g. Career preparation
h. Employment programs/vocational training
i. Budget & financial management
j. Housing education & home management training
k. Health education & risk prevention
l. Family support & healthy marriage education
m. Mentoring
n. Supervised independent living
o. Room & board financial assistance
p. Education financial assistance
Type:
q. Other financial assistance
Section VI: Outcomes
1. Outcomes reporting status:
a. Youth participated
b. Youth declined
c. Incapacitated
d. Incarcerated
e. Runaway/missing
f. Unable to locate or invite
g. Death

(mm/dd/yyyy)

2. Date of outcome data collection:

Responses
Data Elements

Queries

3. Foster care status
4. Current full-time employment
5. Current part-time employment

Youth remains in foster care
Are you currently employed full-time?
Are you currently employed part-time?

6. Employment-related skills

In the past year, did you complete an apprenticeship, internship or other
on the job training, either paid or unpaid?

7. Social Security

Are you currently receiving SSI, Disability or other dependents' payments?

8. Educational aid

Are you currently using a scholarship, grant, stipend, student loan,
voucher or other education financial aid to cover educational expenses?

Page 2 of 3

Yes

No

Declined

Don’t
Know

DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Refugee Resettlement

OMB No. 0970-0034
Exp. XX/XX/XXXX

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information
collection, the Administration for Children and Families (ACF) is gathering data on youth served through the Unaccompanied
Refugee Minors Program including their location, status, and progress. Public reporting burden for this collection of information is
estimated to average .5 hours for respondents from state agencies, 1 hour for respondents from provider agencies, and .5 hours
for youth participants, 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 Office of Management and Budget (OMB) control number. The OMB # is 0970-0034
and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact Anne Mullooly
at [email protected].

Name of Youth
Last

First

Alien Registration No.

HHS Tracking No.

Middle

9. Public financial assistance

Are you currently receiving ongoing welfare [State TANF] payments to
support your basic needs?

10. Public food assistance

Are you currently receiving public food assistance [SNAP or community
program]?

11. Public housing assistance

Are you currently receiving any sort of public housing assistance?

12. Other financial support

Are you currently receiving any periodic and/or significant financial
resources or support from another source not previously indicated and
excluding paid employment?

13. Highest educational certification received

What is the highest educational degree or certification that you have
received?

14. Current enrollment and attendance

Are you currently enrolled in and attending high school, GED classes,
post-high school vocational training or college?

15. Connection to adult

Is there currently at least one adult in your life, other than your caseworker
to whom you can go for advice or emotional support?

16. Homelessness

Have you ever been homeless at any time?

17. Substance abuse referral

Have you ever referred yourself or has someone else referred you for an
alcohol or drug abuse assessment or counseling?

18. Incarceration

Have you ever been confined in a jail or other correctional facility or
juvenile detention in connection with allegedly committing a crime?

19. Children

Have you ever given birth or fathered any children that were born?

20. Marriage at child's birth

If yes, were you married to the child's other parent at the time?

21. Medicaid

Are you currently on Medicaid [or use the name of the State's medical
assistance program under title XIX]?

22. Other health insurance coverage

Do you currently have health insurance other than Medicaid?

23. Health insurance type: Medical

Does your health insurance include coverage for medical services?

24. Health insurance type: Mental health

Does your health insurance include coverage for mental health services?

25. Health insurance type: Prescription drugs

Does your health insurance include coverage for prescription drugs?

26. Health insurance type: Other

Does your health insurance include coverage for other services, e.g.,
dental or vision

a. GED
b. high school diploma
c. vocational certificate
d. vocational license
e. associate's degree
f. bachelor's degree
g. higher degree
h. none of the above
i. declined

Other type of coverage:
Section VII: Report Submission Authority
1. Provider Agency
Agency Name:
Address:
City:

State:

Zip Code:

User Name:

Title:

Phone:

Date: (mm/dd/yyyy)

Email:
Secondary contact:

Title:

Phone:

Email:

2. State/ URD Agency
Agency Name:
Address:
City:

State:

Zip Code:

User Name:
Phone:

Title

Date: (mm/dd/yyyy)

Title:

ORR Approval Date:
(mm/dd/yyyy)

Email:

3. ORR
Name:
Approval/Denial Comments History:

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