ORR-3 Instructions_rev

ORR-3 Placement Report Form Instructions

Unaccompanied Refugee Minors (URM) Program

Office of Refugee Resettlement

What is the ORR-3 Report?

• An initial placement, change of status, termination, or re-entry report for minors and youth in the URM Program.

• Provides basic identifying data, as well as immigration, placement, and legal responsibility data.

• Provides the Office of Refugee Resettlement (ORR) with the youth’s current location and status, which meets requirements of the Immigration and Nationality Act (8 U.S.C. 1522(d)).

• Assists ORR in understanding program effectiveness and broader planning for the URM Program.

Note 1: Failure to provide these reports may result in delay, suspension, or termination of grant support.

Note 2: “URM,” “minor,” or “youth” in the ORR-3 Report Form and Instructions refers to both children under the age of 18 and youth over the age of 18 who are receiving or have received placement, services, and/or benefits funded by ORR.

Who completes and submits the ORR-3 Report?

• The URM provider completes the report form in the URM module of ORR’s Refugee Arrivals Data System (RADS).

• Once the report form is completed, the URM provider submits it to the State Agency.

• The State Agency then reviews the report and submits it to ORR.

How is the ORR-3 Report structured? There are six sections in the report form.

• Section I: Report Action

• Section II: Identifying/Basic Data

• Section III: Immigration

• Section IV: Placement

• Section V: Legal Responsibility

• Section VI: Report Submission Authority

When are the ORR-3 Reports due?

• Initial Placement: due within 30 days of the initial placement into the URM Program.

• Change of Status: due within 60 days of the reportable change.

• Termination from ORR-funded services: due within 60 days of case closure.

• Re-entry for ORR-funded services: due within 60 days of re-entry.

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 .25 hours for respondents from state agencies and .50 hours for respondents from provider agencies, 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].

How is a new URM case created in RADS?

ORR will create case records in RADS for youth who are in the U.S. at the time of referral to the URM Program. However, ORR will not have the case-specific information on a refugee youth who arrives directly to the URM Program from overseas. The URM provider must follow these steps to create a child information record in RADS for refugee youth:

• Under the URM menu, navigate to Cases, then select Add New. After clicking on Add New, a New URM Child Information screen will pop up.

• HHS Tracking No./Case ID and From UC program: These fields are not applicable for refugees who arrive to the URM Program directly from overseas.

• Alien No: Can be found on the I-94.

• Responsible State: Select state where the minor is placed.

• Date of Birth: Enter month, day, and year from an official document such as minor’s I-94 or birth certificate.

• State Agency: Select name of the state agency (this will only populate after Responsible State is selected).

• Responsible Provider: Select local URM provider agency with whom the minor is placed.

• Name: Enter minor’s full name including first, last, and middle (if applicable), as it appears on minor’s I-94 or birth certificate. Include any Alias or Also Known As names.

• Gender: Select female, male, or X (unspecified or another gender).

• Eligibility Date: Enter the month, day, and year the minor became eligible for services. For refugees, the date of eligibility is the date that the minor arrived in the U.S. and can be found on the I-94. For non-refugee cases, do NOT change the eligibility date that was entered in the case record by ORR. The eligibility date for youth who are in the U.S. at the time of referral is the date the youth became eligible to apply for the URM Program (e.g., date of U.S. Department of Homeland Security (DHS)/U.S. Citizenship and Immigration Services (USCIS) adjudication of Special Immigrant Juvenile classification; date of Eligibility Letter from the Office on Trafficking in Persons; date of adjudication of asylum).

• Country of Origin: Enter the name of the minor’s country of nationality, as found on the Bio data form issued by the U.S. Department of State, or birth certificate if available.

• National Placement Agency: Choose the name of the national resettlement agency that assisted in the placement of the youth.

• Add: Once all required information is filled out, click the Add button at the bottom to save the case. Please confirm all information was entered accurately before clicking Add.

How do I begin a new ORR-3 Report in RADS?

• Log in to the URM database using your registered User ID and Password.

  • If you do not have a registered User ID and Password, please contact your state agency.

• Under the URM menu, navigate to Cases, then select “Search.” Search for the case using youth’s identifying criteria. ORR suggests searching by either Alien Number or Case ID, as there are often youth with the same or similar names in the database.

• Click “Edit”, then select “ORR-3” at the bottom. Finally, select “New ORR-3 Form.”

• Begin at Section I: Report Action. Follow instructions below.

Reminders:

• Consult the instructions when you are unsure of what information is to be reported. The instructions can be found in the URM Training Resources library under “General Help” in RADS.

• If you cannot find a youth that has been added by ORR, contact ORR immediately. Do not create a duplicate account. Also, do not change any information in the URM Child Information screen that was entered by ORR. If a change is needed to the data on the URM Child Information screen, contact ORR at [email protected].

• RADS uses controls and auto-population functions. Review data for accuracy prior to submitting to ORR.

SECTION I: REPORT ACTION

1. Initial Placement: Select this option to indicate if a report is an Initial Placement report.

2. Change of Status: Select all related changes and enter date(s) of action(s). Multiple data elements can be selected. When completing the ORR-3 for a ‘change of status,’ only fill out Section I, the information that is new or changing, and Section VI: Report Submission Authority. That is, completing a change of status report does not require filling out the entire form but only the information that is changing. Due to auto-population of past data, it is best practice to review all parts of the form to verify all data is accurate, prior to submission.

• Transfer to/from another URM program: Select if youth transfers to/from another URM program within the same state or a different state. Then, select either “Transfer to” or “Transfer from” followed by the date and name of State Agency and Provider Agency.

  • A transfer to/from will require direct communication with ORR followed by an ORR-3 change of status report for both intrastate and interstate transfers.

  • If a youth comes into your URM Program from another URM Program, you only need to submit a change of status report and do not need to submit an initial ORR-3 placement report again.

  • If it is a transfer to/from another state, the states’ procedures¹ for interstate transfer apply.

  • Note: Transfers to/from another URM Program are to be reported to ORR as a change of status rather than termination and re-entry, since the youth remains in the URM Program. Per ORR, no post-18 interstate transfer is allowed.

• Change in identifying data: Select if youth’s identifying information needs to be changed, such as age/date of birth, name, alien number, eligibility date, or initial placement date.

• Change in age/date of birth. ORR must concur with the age change that was authorized by a court before submission of the ORR-3 Report. Please follow ORR guidance in the online URM Program Policy Guide² on how to seek ORR concurrence with the age change.

• ORR will make the changes in RADS upon receipt of the ORR-3 change of status report.

• Became a parent: Select if youth became a parent through giving birth or fathering a child.

• Change in biological parent’s location: Select if youth’s biological parents’ location has changed.

• Change in immigration data: Select if youth’s immigration status has changed.

• Change in work authorization (i.e., Employment Authorization Document): Select if youth received their Employment Authorization Document (EAD), or there is a change in work authorization (e.g., lost, expired and not renewed.)

• Change in placement type, placement cost, or youth’s address: Select if youth changes placement type, or if there is a change in placement cost or youth’s address. This category includes youth under age 18 who have run away (i.e., absent from program) but legal custody is retained, as well as youth who have an approved absence for more than 30 days (e.g., traveling, visiting family).

  • Note: A change in placement cost, even if placement type or address remains the same, must be reported.

• Establishment of or change in legal responsibility: Select if legal responsibility has been established, changed, or ended by an appropriate court.

• This does not apply to each permanency hearing review. ORR only wants a change of status report should the custodian change, etc.

Explain “Change of Status”: Use the box to provide ORR with additional information if the change requires further explanation.

3. Termination: Provide Final Report for youth terminating URM services, including the date ORR-funded services ended, as well as an explanation of the youth’s destination or current situation at case closure. Only complete Section I and Section VI: Report Submission Authority when submitting a termination report. Select only one reason for termination from the given options.

• Reunified with parents: Select if youth is reunified with parents in the U.S. or overseas, regardless of age of youth.

• Unified with relatives: Select if youth is unified with a relative or a non-relative, and custody or guardianship was obtained by the relative.

• Adopted: Select if youth is legally adopted and, therefore, is no longer eligible to receive any ORR-funded services or benefits.

• Became a U.S. Citizen: Select if youth attains citizenship status while in the program and, therefore, is no longer eligible to receive any ORR-funded services or benefits.

• Emancipated: Select if youth exits the program due to reaching the maximum age for foster care according to state law and is no longer receiving any ORR-funded services.

  • Note: Select the “change in placement type or youth’s address” option under Change of Status, above, if the youth emancipates from foster care and is no longer eligible to receive placement services but continues to receive ORR-funded transition to adulthood services, health coverage, and/or educational benefits. Then, update Section IV: Placement.

• Concluded ORR-funded services/benefits: Select if youth has concluded all ORR-funded services including transition to adulthood services, health coverage, and/or Education and Training Voucher (ETV) benefits.

• Left program voluntarily: Select if youth, although eligible to remain in foster care, leaves the program early prior to age of emancipation. This includes youth who unify with a relative but the relative does not obtain custody or guardianship.

• Not compliant with State/Program Requirements: Select if youth was non-compliant of a voluntary agreement or program rules, or for other violations, which result in the youth’s dismissal from the program.

• Ran away: Select if youth has run away or AWOL from the program, is no longer receiving services, and legal custody is not retained.

• Departed from U.S. (Removal or Voluntary Departure): Select if youth is no longer residing in the U.S., either due to removal by the DHS or voluntary departure.

• Immigration detention: Select if youth has been detained by an immigration authority and is no longer receiving placement and/or services under the URM Program.

• Incarcerated: Select if youth has been incarcerated, whose custody is released, and is no longer receiving placement and/or services under the URM Program.

• Deceased: Select if youth has died while in URM care.

• Other: Any other reasons not identified that result in termination from the program.

4. Re-entered for ORR-funded placement or services: Select for youth re-entering the URM Program. Youth re-entering for URM placement and/or services is limited to youth who were previously enrolled as a URM and who are eligible to return to the program according to the State’s Title IV-B plan. The submission of this report should follow the same 60-day reporting guidelines, as it is considered a change of status.

• URM Placement: Select if youth is re-entering placement. URM placement can include foster family home, therapeutic foster home, group home, supervised independent living, or residential treatment center. Provide date of re-entry.

  • Update Section IV: Placement and any other relevant sections of the report form.

• Services/Benefits only: Select if youth is re-entering to receive ORR-funded services or benefits only, such as transition to adulthood services, health coverage, and/or Education and Training Vouchers (ETVs). Provide date of re-entry.

• Update Sections III: Immigration and V: Legal Responsibility, if necessary.

SECTION II: IDENTIFYING/BASIC DATA

Complete requested information below. Please note that some of the information in this section will auto-populate from the URM Child Information screen.

1. Gender: Data is auto populated from the data entered when the case record was created.

2. Date of Birth: Data is auto populated from the data entered when the case record was created. When a change in Date of Birth is needed, follow instructions found in Section I above.

3. Date of Eligibility: Data is auto populated from the data entered when the case record was created. The date of eligibility signifies the date the youth becomes eligible for the URM program (i.e., date shown on eligibility document); however, it does not confer approval for the URM program. The date of eligibility is different from the date of URM approval (i.e., date shown on URM approval letter). In RADS, for UC to URM transfer cases, the date of eligibility is found on the child info screen and is entered by the ORR/URM case team once the youth has been approved to enter the program. For refugees, the date of eligibility is the date that the youth arrived in the U.S and can be found on the I-94 Arrival Document.

4. Date of Initial Placement: Enter the month, day, and year when URM placement and services commenced. For youth who transfer from the UC program and will remain in the same placement, use the date that the youth was discharged from the UC program. For youth who must travel to their URM placement, please use the date that the youth physically arrived and began receiving URM-funded services. For youth who are approved to enter URM care by ORR, the date of initial placement must never precede the date of URM approval.

5. a) Country of Origin: Data is auto populated from the data entered when the case record was created.

b) Ethnic Group: Enter the youth’s ethnic group, if known. Consult the Reception and Placement Bio Data Form for refugees. If ethnic group is known and not listed as an option, contact ORR at [email protected].

6. a) Language of Origin: Enter the youth’s native or first language.

b) Other Language(s): Enter other languages the youth has acquired.

7. Eligibility Type: Data is auto populated from the data entered when the case record was created.

8. Caseworker/Provider Assessment on Personal Functioning of the Youth (complete at initial placement only): Assess the youth’s functioning in the following domains upon enrollment, using the 5-point scale provided. Provide an explanation, if necessary.

Scale: 1 for poor, 2 for below average, 3 for average, 4 for above average, 5 for excellent.

Assessment domains:

• English Language Skill

• Education (other than English)

• Health Condition

  • Includes both medical and dental health.

• Mental Health

  • Youth’s cognitive, behavioral, and emotional wellbeing that affect their daily life, relationships, and functioning.

Note: While URM youth come from a wide variety of cultural and educational backgrounds, assessment of URM youth should be based on the age-appropriate functioning level of their peers in the general population/community. ORR acknowledges the subjective nature of this assessment but is interested in the baseline functioning of each URM youth at the time of initial placement into the URM Program. For additional guidance and examples on assessing youth functioning, please see Addendum at the end of these Instructions.

9. URM’s Children in Care: If the URM youth is a parent to a child or children with them in care, provide the name (First Name, Middle Name, Last Name), date of birth, and citizenship/immigration status for each child. Do not include information on dependent children of URM youth who does not reside with the URM in the program, and reside either in home country or in another location within the U.S.

10. Mother of URM: Provide the mother’s last, first, and middle names.

1. Indicate "Yes," "No," or “Unknown” as to whether the mother of the youth is living.

2. Provide her last known address at the time the youth arrived in the U.S.

3. Provide the current address of mother, if different from above address.

11. Father of URM: Provide the father’s last, first, and middle names.

a) Indicate "Yes," "No," or “Unknown” as to whether the father of the youth is living.

b) Provide his last known address at the time the youth arrived in the U.S.

c) Provide the current address of father, if different from above address.

SECTION III: IMMIGRATION

1. Immigration: Select the youth’s immigration status from the following options. Please reference Policy Letter 16-01³, PL 16-01 document guide⁴, PL 16-01 FAQ⁵, PL 22-02⁶, and PL 22-13⁷ or the online URM Program Policy Guide⁸ for additional guidance⁹.

• Refugee: Select if youth has an I-94 documenting refugee status but is not yet a Lawful Permanent Resident. Other acceptable documentation includes Visa 93 on the Form I-94¹⁰, Form I-765 Employment Authorization Document receipt notice with the code A03, Form I-766 Employment Authorization Document with code A03, Form I-571 United States Refugee Travel Document¹¹, Form I-730 Approval letter.

• Asylee: Select if youth has a letter from USCIS, an Immigration Judge’s order granting asylum, or a written decision from the Board of Immigration Appeals (BIA) but is not yet a Lawful Permanent Resident. Other acceptable documentation includes Form I-94 with code AS1, AS2 or AS3, Visa 93 on the Form I-94¹², Form I-571 United States Refugee Travel Document¹³, Form I-765 Employment Authorization Document receipt notice with the code A05, Form I-766 Employment Authorization Document with code A05, Form I-730 Approval letter.

• SIJ (I-360 approval): Select if youth has documentation of USCIS approval of an I-360 petition but is not yet a Lawful Permanent Resident.

• Afghan Humanitarian Parolee: Select if youth has a Form I-94, or a foreign passport with admission stamp with any of the following notations: “OAR,” “OAW,” “DT,” “PAR”, “PAROLED” or Humanitarian Parole per INA §212(d)(5). Other acceptable documentation includes Form I-765 Employment Authorization Document receipt notice with code C11 or Form I-766 Employment Authorization Document with code C11.

• Ukrainian Humanitarian Parolee: Select if youth is a Ukrainian citizen or national who has a Form I-94, or a foreign passport with admission stamp with any of the following notations: “DT,” “U4U,” “UHP,” or Humanitarian Parole per INA §212(d)(5). Other acceptable documentation includes Form I-765 Employment Authorization Document receipt notice with code C11 or Form I-766 Employment Authorization Document with code C11. Select also if youth is a non-Ukrainian individual who has any of the forms or stamps listed previously, and documentation of last habitual residence in Ukraine, including but not limited to original Ukrainian government-issued document, such as current driver’s license or identification card.

• Cuban/Haitian Entrant-No immigration status: Select if youth has an I-94, parole, Notice to Appear, or other document establishing them as a Cuban/Haitian Entrant, as long as no final, non-appealable and legally enforceable order of removal, deportation or exclusion has been entered.

• Victim of Trafficking-No Immigration Status (OTIP letter only): Select if youth has a Letter of Eligibility from the ACF Office on Trafficking in Persons (OTIP) and no other immigration status.

• U-Status Recipient: Select if youth has received documentation of U Status from USCIS.

• T-Status Recipient: Select if youth has received a documentation of T Status from USCIS.

• Lawful Permanent Resident: Select if youth has adjusted status to lawful permanent residency and is in receipt of their green card. This could include refugees, asylees, or SIJs with an approved I-485 application.

• Other: Select if youth has an immigration status not mentioned above. Describe immigration status in the text field provided.

2. Youth is receiving immigration assistance: Indicate if youth is receiving immigration assistance by selecting “Yes” or “No.”

3. Youth has work authorization/Employment Authorization Document: Indicate if youth has work authorization/Employment Authorization Document by selecting “Yes” or “No.” If youth is authorized to work because of their immigration status but does not have an EAD, select “No.” Once the youth receives their EAD, a Change of Status report should be submitted reporting a change in work authorization.

Note: A change in immigration status may mean the youth is no longer eligible for the URM Program. Consult ORR immediately with any questions.

SECTION IV: PLACEMENT

1. Placement Type: Select the appropriate option to indicate the type of placement for the youth.

• Foster Family Home: Select if youth is placed in a conventional foster family home. In general, foster family homes meet the standards established for licensing or approval by the state and are provided a regular foster care maintenance rate. For completing the ORR-3, youth placed in foster family homes do not require the additional care or treatment provided by therapeutic foster homes.

  • May include relative/kinship foster care placements or agency-operated homes with foster parents who are employees of the URM provider agency.

• Therapeutic Foster Home: Select if youth is placed in a therapeutic foster home. Therapeutic foster homes are licensed at a therapeutic level by the state and/or meet criteria in the state’s agreement with the URM provider as a therapeutic foster home. Therapeutic foster home parents have received additional training to meet the needs of youth with mental health or behavioral health needs, in a family setting. Youth placed in therapeutic foster homes require emotional or behavioral therapeutic interventions and a higher level of care than is provided in a conventional foster family home, but do not require placement in a more restrictive setting. Therapeutic foster homes typically receive higher maintenance rates than conventional foster family homes.

• Group Home: Select if youth is placed in a group home setting licensed or approved by the state. Settings can include therapeutic group homes or transitional group homes.

  • Therapeutic group homes provide on-site treatment planning and services in a non-secure setting for youth with significant emotional or behavioral problems who have the capacity to engage in community-based activities. Treatment services typically include individual and group therapy/counseling, behavior modification, recreational therapy, or skill building. Therapeutic group homes offer a less restrictive environment than residential treatment but are more restrictive than therapeutic foster homes. Therapeutic group homes are in the community where residents attend local schools and have around-the-clock staffing onsite.

  • Transitional group homes provide mostly independent living skill-building services that focus on transition to adulthood. Transitional group homes may or may not have around-the-clock staffing onsite.

• Supervised Independent Living: Select if youth is placed in supervised independent living. Supervised independent living may also be referred to as semi-independent living. For the purpose of completing the ORR-3, youth placed in supervised independent living may:

  • Not be supervised 24 hours a day, but an agency or adult is responsible and accountable for the youth’s wellbeing and safety;

  • Continue to receive case management services;

  • Be given increased responsibilities for managing their own living arrangements (e.g., paying bills, assuming leases, and working with a landlord).

• Residential Treatment: Select if youth is placed in a residential treatment facility. For the purpose of completing the ORR-3, residential treatment:

  • Is a live-in health care facility that provides treatment/therapeutic services for mental illness, substance abuse, and/or behavioral issues in a secure and/or restrictive setting for youth who, because of the severity of their issues, are unable to adjust to other placements but do not require inpatient psychiatric hospitalization;

  • May include crisis stabilization, initial and continuing bio-psychosocial assessment, care management, medication management, therapy and mobilization of family support and community resources in the context of a comprehensive multidisciplinary treatment plan;

  • Develops a plan for the youth to step down into a lesser restrictive, non-secure setting once treatment goals are met.

• Long-term hospitalization (more than 2 weeks): Select if youth has been hospitalized more than 2 weeks, for either medical or psychiatric reasons.

• Absent from program but legal responsibility retained: Select if a state, county, or program still retains legal custody of a minor under 18 who has run away or has been detained. There is no need to update any part of the form unless other changes have been indicated.

• Living independently but receiving ORR-funded services/benefits: Select if youth is living independently (i.e., not receiving any placement services), but is still receiving ORR-funded services or benefits such as transition to adulthood services, Education and Training Vouchers (ETVs), and/or health coverage. Occasional minimal staff support can be provided on a case-by-case basis.

• Other: Select if youth is placed in a setting other than the options provided and describe the placement setting.

1. Placement Cost: Enter the average daily rate in dollars related to placement type.

• For youth in foster homes, enter the foster care maintenance rate provided to the licensed foster family.

• For placements through a contract (e.g., group home, residential treatment), enter the per diem cost.

• For youth categorized as “No Placement (but receiving ORR-funded services/benefits),” enter the stipend amount provided to the youth to help pay for their rent.

• Do not include administrative costs (e.g., staffing) or other direct service costs (e.g., transportation, interpretation) in the average daily rate.

3. Youth’s Residence: Enter the name and relation of the caregiver, if relevant, in addition to the address of the youth.

4. Provider Agency for Placement: If “Same as URM provider” is selected, this information will auto-populate from the first page. If different from the URM provider agency, then select “Placement via Subcontract.”

Note 1: Do not report change in placement if youth is placed in respite care that is less than 30 days.

Note 2: Job Corps can be reported as either supervised independent living or living independently, depending on the state’s discernment.

SECTION V: LEGAL RESPONSIBILITY

1. Legal responsibility has been petitioned. Select from the following options:

• Yes, it was petitioned within 30 days of enrollment. Select if procedures to establish legal responsibility for the minor were initiated with an appropriate court within 30 days of the minor’s arrival at the URM Program. Enter the date the petition was filed.

• Yes, it was petitioned past 30 days of enrollment. Select if procedures to establish legal responsibility for the minor were initiated with an appropriate court after 30 days of the minor’s arrival at the URM Program. Enter the date the petition was filed.

• No, it hasn’t been petitioned. Select if procedures to establish legal responsibility for the minor have not yet been initiated with an appropriate court.

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

• Check the appropriate box to indicate “Yes” or “No.”

  • “Yes” indicates that legal responsibility was established for the minor in accordance with applicable State law. Enter the date that the court established legal responsibility.

  • “No” indicates that legal responsibility was not established for the minor in accordance with applicable State law.

• Select “Pending” if procedures were initiated to establish legal responsibility for the minor in accordance with applicable State law, but legal responsibility has not yet been established.

2.a. In lieu of initial establishment of legal responsibility, youth has signed Voluntary Placement Agreement (VPA). Select “Yes” if the youth signed a VPA in lieu of initial establishment of legal responsibility. Enter the date youth signed the VPA. Select “No” if the youth did not sign a VPA.

Note: Currently, 2.a. (VPA signed in lieu of legal responsibility) is applicable to the state of Massachusetts only. Select “N/A” if not Massachusetts.

3. Court name with jurisdiction: Provide the name of the court that has jurisdiction over the youth.

4. Agency name to whom legal responsibility assigned: Provide the name of the agency with legal responsibility for the youth. If the same as URM provider, check corresponding box.

5. Legal responsibility has ended. Select “Yes” if the legal responsibility has ended (i.e., terminated by a court or per State law) and enter the date that legal responsibility has ended. Select “No” if legal responsibility is still intact (i.e., the youth still has a legal custodian/guardian per court rules or State law). If the youth exits the program at the maximum age for legal responsibility in the state, it is not necessary to submit a Change of Status to report the ending of legal responsibility; a final termination report will signal ending of legal responsibility.

SECTION VI: REPORT SUBMISSION AUTHORITY

The agency information will auto-populate from the first page. Complete user information only.

1. Provider Agency:

• Provide the name, title, phone number, and email address of the person preparing the report and the date the report was approved to be submitted to the state. Include a secondary contact at the provider agency.

• Do not backdate approval of reports.

2. State/URD Agency:

• Provide the name, title, phone number, and email address of the state official submitting the report, and the date the report was approved to be submitted to ORR.

• Do not backdate approval of reports.

• When returning reports for revisions to the URM provider agency, it is important to clearly identify the issue and explain corrective measures.

3. ORR: Provide the name, title, and approval date. Enter any comments on the approval or denial of the report.

ADDENDUM: Guidance for Caseworker/Provider Assessment of Youth Functioning for Section II.8.

Below are example criteria that can be used to help guide the ratings a caseworker selects. These are just examples to help provide some consistency; the examples should not be used as explicit criteria where youth must “check off” each element.

	Poor	Below Average	Average	Above Average	Excellent
English Language Skill	Client has no English skills. Client is not enrolled in ESL classes. Client requires interpretation.	Client has limited English conversational, reading and/or writing skills. Client is enrolled in ESL classes or other language instruction. Client requires interpretation for most interactions.	Client speaks conversational with reading and writing skills. Client no longer requires ESL classes. Client requires interpretation for specialized services (e.g. medical and legal).	Client communicates effectively in English through speaking, reading, and writing. Client requires interpretation rarely, utilizes interpreter or technology resources when the need arises.	Client is fully proficient in English. Client can read and write in English. Client does not require interpretation.
Education (other than English)	Client has no prior educational experiences or has a gap of several years in education. Client is not enrolled in school or refuses to attend school.	Client has gaps in prior educational experiences. Client unable to complete age-appropriate coursework without significant support. Client enrolled in school, has poor attendance.	Client completes age-appropriate coursework, receives age-appropriate supports such as tutoring. Client is enrolled and consistently attends school. Client is passing classes and advancing in their education.	Client completes age-appropriate coursework, with minimal or no educational supports. Client is enrolled and has consistent attendance at school. Client has passing or good grades, has a plan for future education or career goals.	Client excels in classes with age-appropriate peers. Client does not require educational supports, such as tutoring. Client receives good to excellent grades. Has completed, or is on track to complete, a high school education. Has a plan for future education or career goals.
Health Condition	Client has untreated or unaddressed medical needs. Client not receiving needed medical care for a chronic condition(s).	Client is inconsistent in managing health needs. Client has a present illness or physical health concern that is not stable.	Client has a medical condition, with proper treatment received. Client is stable in managing chronic health condition(s) with support.	Client reports mostly good health. Client does not have any new health concerns. Client is stable in managing chronic conditions with minimal support.	Client has no medical conditions and is in good health. Client has medical conditions that are well managed independently.
Mental Health	Client has mental health conditions unaddressed or untreated. Client demonstrates patterns of instability including plans to harm self or others.	Client has identified mental health concerns, bouts of instability, and/or refusing treatment. Client reports some ideation of harming self or others, but denies plan, intent, or means.	Client presents as mostly stable and mostly uses age-appropriate emotional regulation skills. Client is aware of mental health needs and is receiving regular treatment or support.	Client does not report, or does not demonstrate, behaviors indicating mental health concerns. Client is receiving treatment and effectively managing mental health needs with support.	Client does not report, or does not demonstrate, behaviors indicating mental health concerns. Client has mental health conditions that are well managed independently.

1 Per 45 CFR 400.119

2 https://www.acf.hhs.gov/orr/resource/orr-guide-to-eligibility-placement-and-services-for-unaccompanied-refugee-minors-urm

3 https://www.acf.hhs.gov/orr/resource/policy-letter-16-01

4 https://www.acf.hhs.gov/orr/policy-guidance/status-and-documentation-requirements-orr-refugee-resettlement-program

5 https://www.acf.hhs.gov/orr/faq/pl-16-01-frequently-asked-questions

6 https://www.acf.hhs.gov/sites/default/files/documents/orr/ORR-PL-22-02-Additional-ORR-Eligibility-Categories-and-Documentation-Requirements-for-Afghan-Nationals-Revised.pdf

7 https://www.acf.hhs.gov/sites/default/files/documents/orr/PL-22-13-Ukrainian-Humanitarian-Parolees-Eligible-for-ORR-Benefits-and-Services.pdf

8 https://www.acf.hhs.gov/orr/resource/orr-guide-to-eligibility-placement-and-services-for-unaccompanied-refugee-minors-urm-section-1#1.1

9 Please note that there may be periodic updates to the documentation policy letters. For more updated information, please refer to the policy letters.

10 May be accompanied by the words “section 207”; typically issued when the individual is the spouse or child of a previously admitted refugee.

11 The DHS Form I-571 United States Refugee Travel Document does not distinguish between refugees and asylees. An individual with a United States Refugee Travel Document may be a refugee or an asylee.

12 May be accompanied by the words “section 208”; typically issued when the individual is the spouse or child of a previously admitted asylee.

13 The DHS Form I-571 United States Refugee Travel Document does not distinguish between refugees and asylees. An individual with a United States Refugee Travel Document may be a refugee or an asylee.

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