Form ORR-3 URM Placement Report

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: