ORR-4 URM Outcomes Report

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

ORR-4 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-4 REPORT FORM
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM
OUTCOMES REPORT


State/ URD Agency
Provider Agency




Agency Name:


Agency Name:


Address:


Address:


City:

City:

State:
Zip:

State:
Zip:



Section I: Report Action





















1. Annual Outcomes Report



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






Alternative to High School









Less than 6th grade















6th grade















7th grade






11th grade








8th grade






12th grade







9th grade





Dual-credit program








10th grade






No Grade Assigned








11th grade





GED program









12th grade





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.








Yes


No





















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 Below Average Average Above Average Excellent Explain

English Language Skill




Education (other than English)




Social Adjustment




Health Condition




Mental Health




Preservation of Ethnic and Religious Heritage




Readiness to Live Independently






Section IV: Family Reunification


1. The youth has a permanency plan.






Yes

No






















a. The youth's most recent primary permanency goal was:












Adoption


Guardianship



Reunification







Another Planned Permanent Living Arrangement (APPLA)
















Permanent Placement with Fit and Willing Relative (PPFWR)
































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.










Yes

No


If Yes, describe efforts and significant developments:





















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










Yes





















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













q. Other financial assistance



Type:








Section VI: Outcomes


















1. Outcomes reporting status:
2. Date of outcome data collection: (mm/dd/yyyy)

a. Youth participated



b. Youth declined










c. Incapacitated










d. Incarcerated










e. Runaway/missing










f. Unable to locate or invite










g. Death



























Data Elements Queries Responses
Yes No Declined Don’t Know
3. Foster care status Youth remains in foster care


4. Current full-time employment Are you currently employed full-time?

5. Current part-time employment 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?

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?

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


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

Other type of coverage:


Section VII: Report Submission Authority
1. Provider Agency

Agency Name:


Address:


City:

State:
Zip Code:




User Name: Title: 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 Date: (mm/dd/yyyy)




Phone:
Email:



















3. ORR
















Name: Title: ORR Approval Date:


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

















































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