R-10 Program Exit Processing - Modernized UC Portal

OMB 0970-0552 [valid through MM/DD/YYYY]

Administration for Children & Families

Office of Refugee Resettlement

Program Exit Processing

Child Basic Information

Photo of Child [auto-populated]	First Name: [auto-populated]	AKA: [auto-populated]
	Last Name: [auto-populated]	Status: [auto-populated]
	Date of Birth: [auto-populated]	Admitted Date: [auto-populated]
	A#: [auto-populated]	Length of Stay: [auto-populated]
	Country of Birth: [auto-populated]	Current Program: [auto-populated]
	Gender: [auto-populated]	Portal ID: [auto-populated]

Exit Processing Basic Information

Discharge Type: [dropdown] Reunified (Individual Sponsor) Reunified (Individual Sponsor) – Court-Ordered Reunified (Individual Sponsor) – Immigration Relief Granted Transfer of Placement Age Out Age Redetermination Voluntary Departure Child Deceased Determined to be U.S. Citizen Discharged to Program/Facility Discharged to Program/Facility – Court-Ordered Discharged to Program/Facility – Immigration Relief Granted Government Agency Joint Removal with Parent (VD Order for UC) Joint Removal with Parent (NTA Cancelled) Ordered Removed Ran Away from Facility Ran Away on Field Trip Referral Cancelled – OCONUS Age Out Referral Cancelled by Referring Agency UC Child Discharged with UC Parent U.S. Citizen Child Discharged with UC Parent Other If Other, specify: [text box – only appears if Other selected]	Status: [dropdown] Cancelled Discharge – Initiated Discharge – On Hold Discharge – In Transit Discharge – Completed
Scheduled Date of Discharge: [date picker]
Date of Discharge: [date picker]	Time of Discharge: [text box]
Is there a delay in discharging the child? [dropdown – Yes/No]	Discharge Delay Reason: [dropdown – only appears if Is there a delay in discharging the child? = Yes] Flight Delayed/Cancelled Health – New disease exposure resulting in quarantine Health – Sudden Onset of medical/mental health issue (with or without isolation) Natural Disaster at Destination Sibling/Relative Group Sponsor Detained Sponsor Lost ID Sponsor Scheduling Issues Travel – Program Delay Travel – Transportation Contractor Delay Travel – Weather Delay Travel – Non-Weather Delay U.S. Newborn Pending BC/Medical Insurance Other If Other, specify: [text box – only appears if Other selected]
Date Delay Reported: [date picker – only appears if Is there a delay in discharging the child? = Yes]	Date Delay Resolved: [date picker – only appears if Is there a delay in discharging the child? = Yes]
Discharge Delay Comments: [text box – only appears if Is there a delay in discharging the child? = Yes]
UC Parent Discharge Type: [dropdown – only appears if Discharge Type = UC Child Discharged with UC Parent or U.S. Citizen Child Discharged with UC Parent] Age Out Age Redetermination Discharged to Program/Facility Discharged to Program/Facility – Court-Ordered Discharged to Program/Facility – Immigration Relief Granted Government Agency Joint Removal with Parent (VD Order for UC) Joint Removal with Parent (NTA Cancelled) Ordered Removed Reunified (Individual Sponsor) Reunified (Individual Sponsor) – Court-Ordered Reunified (Individual Sponsor) – Immigration Relief Granted Voluntary Departure Other	UC Parent Name: [text box – only appears if Discharge Type = UC Child Discharged with UC Parent or U.S. Citizen Child Discharged with UC Parent]
If Other, specify: [text box – only appears if Other selected]	UC Parent A#: [text box – only appears if Discharge Type = UC Child Discharged with UC Parent or U.S. Citizen Child Discharged with UC Parent]

Exit Processing Details

[Fields appearing in this section depend upon the Discharge Type selected. This section does not appear at all if Discharge Type = Ran Away from Facility, Ran Away on Field Trip, Referral Cancelled – OCONUS Age Out, Referral Cancelled by Referring Agency, or Other]

1 [Below fields appear if the Discharge Type = any of the Reunified (Individual Sponsor) options; or if Discharge Type = UC Child Discharged with UC Parent and UC Parent Discharge Type = any of the Reunified (Individual Sponsor) options]
ORR Decision: [auto-populated]
Last Updated Date/Time: [auto-populated]
Sponsor Name: [auto-populated]	Sponsor Date of Birth: [auto-populated]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]
Primary Phone: [auto-populated]	Backup Phone Number: [auto-populated]
Relationship to UC: [auto-populated]

2 [Below fields appear if the Discharge Type = any of the Discharged to Program/Facility options; or if Discharge Type = UC Child Discharged with UC Parent and UC Parent Discharge Type = any of the Discharged to Program/Facility options]
Program Name: [auto-populated]	Program Type: [auto-populated]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]

3 [Below fields appear if the Discharge Type = Transfer]
Receiving Program Name: [auto-populated]	Receiving Program Type: [auto-populated]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]

4 [Below fields appear if the Discharge Type = Government Agency, Joint Removal with Parent (VD Order for UC), or Ordered Removed; or if Discharge Type = UC Child Discharged with UC Parent and UC Parent Discharge Type = Government Agency, Joint Removal with Parent (VD Order for UC), or Ordered Removed]
Government Agency Name: [text box]	Government Agency Type: [dropdown] Child Protective Services DHS Family Shelter ICE ERO Local Law Enforcement Marshal’s Service
Address: [text box]	City: [text box]
State: [text box]	Zip Code: [text box]

5 [Below fields appear if the Discharge Type = Voluntary Departure or Joint Removal with Parent (VD order for UC); or if Discharge Type = UC Child Discharged with UC Parent and UC Parent Discharge Type = Voluntary Departure or Joint Removal with Parent (VD order for UC)]
Date Granted Voluntary Departure: [date picker]	Date Travel Document Requested: [date picker]
Referral to Services in Country of Origin: [dropdown] If Other, specify: [text box – only appears if Other Services selected] Options: KIND CMRRP ISS International Social Services Other Services Not Applicable	Date Travel Document Issued: [date picker]
Completed Referral to Services in Country of Origin: [dropdown – Yes/No/Not Applicable]

6 [Below fields appear if the Discharge Type = Age Out or Age Redetermination]
DHS Age Out/Age Redetermination Plan: [dropdown] DHS Release on Own Recognizance DHS Approved Post-18 Plan Discharge to ICE Custody ICE Young Adult Case Management Program (YACMP) (if applicable) Unknown	Type of Post-18 Discharge Plan: [dropdown – only appears if DHS Age Out/Age Redetermination Plan = Approved Post-18 Plan] Potential Sponsor (did not complete sponsorship process) Other Family Member Shelter/Facility
Address: [text box]	City: [text box]
State: [text box]	Zip Code: [text box]

7 [Below fields appear if the Discharge Type = Determined to be U.S. Citizen]
Discharged into Custody of: [dropdown] Individual Program/Facility	Name: [text box]
Address: [text box]	City: [text box]
State: [text box]	Zip Code: [text box]

8 [Below fields appear if the Discharge Type = U.S. Citizen Child Discharged with UC Parent]
UC Parent Discharged into Custody of: [dropdown] Individual Sponsor Program/Facility	Name: [text box]
Address: [text box]	City: [text box]
State: [text box]	Zip Code: [text box]

Transportation Details

[Below fields will appear in case management system but will not appear in generated PDF generated that is shared with external stakeholders]

Method of Transportation: [dropdown] If Other, specify: [text box – only appears if Other selected] Bus Flight Train Sponsor Pick-Up DHS Transport Other	Transport Fees Paid by ORR: [dropdown – Yes/No]
Did the program medical coordinator (or designated staff) certify that the child is medically fit to travel? [dropdown – Yes/No]	Are any health-related travel restrictions/accommodations needed (e.g., cannot travel longer than 3 hours at a time, requires a wheelchair)?
Does the UC need an escort? [dropdown – Yes/No]	Type of Escort: [dropdown] Care Provider Escort to Offsite Location Travel via Airline
Name of Escort: [text box]	Escort Contact Number: [text box]

Child Legal and Immigration Information

Parent/Legal Guardian Separation: [auto-populated from R-4]	MPP Case: [auto-populated from R-4]
Next Scheduled Court Appearance (EOIR): [date picker]	Next Scheduled Court Appearance (non-EOIR): [date picker]
UC Legal Status: [dropdown] NTA (in removal proceedings) Without status SIJS: I-360 approved SIJS: I-485 approved LPR derivative (of U.S. relative) LPR other Asylum: Immigration Judge Initial Order w/ 30-day appeal period Asylum: Immigration Judge Final Order w/ 30-day appeal period waived or completed Asylum: Appealed to federal court Asylum: USCIS grant U.S. Citizen Temporary Protected Status T-nonimmigrant status U-nonimmigrant status Other non-immigrant visa F-1 student visa (non-immigrant status) B-1/2 Tourist/business visa (non-immigrant status) Continued Presence Withholding of Removal Humanitarian Parole Final Order of Removal Other If Other, specify: [text box – only appears if Other selected]	Date sponsor notified that they must inform EOIR directly of any further changes of address: [date picker]
Reason for less than 48 hours’ advance notice of discharge to Immigration and Customs Enforcement (if applicable): [text box]

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to process the physical discharge of a child from a care provider program when the child has been approved for release/discharge from ORR custody or for transfer within the ORR provider network . Public reporting burden for this collection of information is estimated to average 0.25 hours per response, 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 (Homeland Security Act, 6 U.S.C. 279). 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 OMB control number. If you have any comments on this collection of information please contact [email protected].

R-10 | Version # Page 1 of 5

Revised MM/DD/20YY