Form TBD Category 4 Reunification Case Review and Staffing

OMB #: 0970-0XXX, Valid Through MM/DD/YYYY

Administration of Children and Families

Office of Refugee Resettlement

Category 4 Reunification Case Review and Staffing (Form TBD-#) Reunification is a collaborative process involving the child, their parents, legal guardians, immediate and extended family members, other relatives, godparents and friends, case managers, lead case managers, clinicians, supervisors, and program managers. INSTRUCTIONS TO CASE MANAGER: Complete Sections A and B AFTER you have conducted a full review of the child’s case file and completed the Mobility Mapping activity in partnership with the child.
SECTION A: SPONSORSHIP RECORD
Date Mobility Map Completed:				Case Manager Name:			Supervisor Name:
Child’s Name:				A#:			LOS (Provider):
Child Age:				Nationality:			LOC (ORR Care):
Sex:		Male Female		Is the child accompanied by sibling(s) and/ or their child(ren):				Yes No
If yes, list relationship, age, sex , and location of sibling(s) and/ or child(ren):
How many previous potential and actual sponsors did the child have across ALL Programs (include every individual listed in the case notes even if NOT entered in the sponsor section of the UAC Portal)?						0 1 2 3 4 5 6 7
How many sponsors were denied due ONLY to safety concerns and/or flags? Do NOT include sponsors who withdrew or were denied for other reasons (ex: HHM not complying)						0 1 2 3 4 5 6 7
List the reason(s) why every sponsor was denied, withdrew, or never moved forward with sponsorship.
Name			Reason
Name			Reason
Name			Reason
Name			Reason
Name			Reason
Name			Reason
Name			Reason

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to enable care provider facilities to create a discharge plan for children who are not likely to be released to a sponsor that addresses the child’s individual needs. Public reporting burden for this collection of information is estimated to average 2.19 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, and Trafficking Victims Protection Reauthorization Act, 8 U.S.C. 1232). 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].

Does the child have social media account(s)?					Yes No
If yes, was the child able to contact any potential sponsor using social media?					Yes No (If “No” explain)
Indicate all individuals the Case Manager communicated with in the past to attempt to identify or find contact information for a potential sponsor (Policy 2.2.1).					Mother Father Adult Sibling(s) Maternal Aunt(s) Maternal Uncle(s Paternal Aunts(s) Paternal Uncle(s) Cousin(s) Other(s) _________________
Did the Case Manager speak with any potential sponsors recently who were NOT denied due to safety concerns to assess their willingness to re-consider sponsorship? For ex: HHMs not wanting to comply, negative Home Study etc.					Yes No (if “No” explain why)
Fill in the table below with information regarding: Previous potential and actual sponsors who do NOT pose a safety concern and/or who are NOT flagged who were contacted again during this review, New potential sponsor(s) identified by the child in the Mobility Map, and New potential sponsor(s) identified by the child’s immediate and extended family members and caregivers.
Name of Sponsor		Sponsor Category	Who informed you of this sponsor? (Ex: Aunt, Child via Mobility Map, etc.)	Date of recent communication		Willing to consider sponsorship? (Yes / No)	Reason(s)
Ex: Alfredo Padilla		Cat 3	Maternal Aunt	12/22/2023		No	Just arrived in the United States and needs time to find housing and a job.

SECTION B: CASE PLANNING NOTES

INSTRUCTIONS TO CASE MANAGER: Consider the following questions and record notes below in preparation for Staffing. Feel free to add space as necessary

1. What are the current reunification options for the child (list all possible sponsors who are being explored and/or will be explored)? Do NOT include LTFC or URM as options, only list the reunification options that will be explored.

2. If there are no current reunification options, list ALL extended family members and caregivers the Case Manager will communicate with BEFORE Staffing to attempt to identify a sponsor and/or to get contact information for potential sponsors (Policy 2.2.1).

SECTION C: STAFFING NOTES

INSTRUCTIONS TO CASE MANAGER: Complete this section after a case-plan has been identified during Staffing with ORR staff.

What are the best possible – but realistic - paths to reunification for this child? Briefly state the concurrent directions the team recommends for moving forward, anticipated barriers, and plans to overcome identified barriers. What needs to happen next to work towards reunification. What are the action steps that will be taken and when. What barriers or challenges need to be addressed to successfully accomplish the identified action-steps. Focus on what is possible to achieve within the next 30 to 90 days.

Do NOT include LTFC or URM as options, only list the paths that will be explored to achieve reunification.

Path #1

Path #2

Form TBD-# | Version 1.0

MM/DD/YYYY 1 of 3