Form A-15 Form A-15 ORR Waiver Request

Office of Refugee Resettlement Waiver
Request
VERSION 2 (REVISED MM/DD/YYYY)
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The
purpose of this information collection is to allow care providers, as well as home study and post-release
service providers, to request a waiver of a regulatory, policy, procedure, or cooperative agreement
requirement when appropriately justified and when the safety and well-being of children in Office of
Refugee Resettlement custody will not be adversely affected. Public reporting burden for this collection
of information is estimated to average 0.33 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. The OMB control number is 0970-0547 and the expiration date is MM/DD/YYYY. If you
have any comments on this collection of information please contact [email protected].

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Office of Refugee Resettlement (ORR) Waiver Request

* Required

Provider Information
Provider Name *
Enter your answer

Provider Address *
Enter your answer

Provider Type
Care Provider Facility
Home Study or Post-Release Service Provider
Out-of-Network Facility
Out-of-Network Level of Care *

Only appears if user selects "Out-ofNetwork Facility" above

Enter your answer

Level of Care *

Only appears if user selects "Care Provider Facility" above

Emergency or Influx Care Facility (EIF)
Shelter
Group Home
Transitional Foster Care (TFC)
Long-Term Foster Care (LTFC)
Heightened Supervision Facility
Secure
Residential Treatment Center (RTC)
Therapeutic Group Home

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Office of Refugee Resettlement (ORR) Waiver Request

* Required

Primary Point of Contact (POC) Information

POC Name *
Enter your answer

POC Phone Number *
Enter your answer

POC Email *
Enter your answer

POC Title *
Enter your answer

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Office of Refugee Resettlement (ORR) Waiver Request

* Required

Waiver Request
Project Officer or Contracting Officer’s Representative’s Email *
.gov email addresses only. The request will be routed to this person.
Enter your answer

Waiver Request Type *
Initial Request
Renewal Request

Date of Initial Request *

Only appears if user selects "Renewal Request" above

Enter your answer

Requested Timeframe of Waiver *
Enter your answer

Specific Waiver Being Requested *
Enter your answer

Why is the waiver needed? *

Include the specific provision you are unable to meet and why along with a description of efforts
made to rectify the issue prior to submitting this waiver.
Enter your answer

What other provisions or mitigations can be implemented to maintain quality or reduce
risk, including related state licensing requirements that will be adhered to? *
Enter your answer

Was a supervision or training plan developed as part of this waiver request? *
Yes
No
Upload the supervision or training plan *

Only appears if user selects "Yes" above

Upload file
File number limit: 1 Single file size limit: 100MB Allowed files types: Word, Excel, PPT, PDF, Image, Video, Audio

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