URM ORR-3 and ORR-4 Report Forms

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Office of Refugee Resettlement

OMB No. 0970-0034
Exp. 11/30/2026

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 11/30/2026. If you have any comments on this
collection of information, please contact Anne Mullooly at [email protected].

Name of Youth
First

Last

Alien Registration No.

HHS Tracking No.

Middle

ORR-3 REPORT FORM
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM
PLACEMENT REPORT
State/URD Agency
Agency Name:
Address:
City:
State:

Provider Agency
Agency Name:
Address:
City:
State:

Zip:

National Voluntary Agency

USCCB

Zip:
LIRS

Not Applicable

Section I: Report Action
1. Initial Placement - Must be submitted within 30 days of placement
2. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change
Transfer to/from another URM Program
Transfer to

Date of Action (mm/dd/yyyy)

Transfer from

State Agency:
Provider Agency:
Change in identifying data (e.g., age, name, or A#)
Became a parent
Change in biological parent's location
Change in immigration data
Change in work authorization (i.e., Employment Authorization Document)
Change in placement type, placement cost, or youth's address
Establishment of or change in legal responsibility
Explain "Change of Status".

3. Termination:

Date of Termination:

Reunified with parents
Unified with relatives
Adopted
Became a U.S. Citizen
Emancipated
Concluded ORR-funded services/benefits
Left program voluntarily

Not compliant with State/Program requirement(s)
Ran away
Departed from U.S. (Removal or Voluntary Departure)
Immigration detention
Incarcerated
Deceased
Other

Explain destination/current situation at case closure.

4. Re-entered for ORR-funded placement or services

Date of Re-entry (mm/dd/yyyy)

Services/Benefits only

URM Placement
Section II: Identifying/ Basic Data
1. Sex:

2. Date of Birth
Female

3. Date of Eligibility

Male

5a. Country of Origin:

5b. Ethnic Group:

6a. Language of Origin:

6b. Other Language(s):

4. Date of Initial Placement

Name of Youth
First

Last

Alien Registration No.

HHS Tracking No.

Middle

7. Eligibility Type:
Refugee

Asylee

Special Immigrant Juvenile (SIJ)

C/H Entrant

U-Status Recipient

Afghan Humanitarian Parolee

Trafficking Victim

Ukrainian Humanitarian Parolee
Other:

Name of Youth
First

Last

Alien Registration No.

HHS Tracking No.

Middle

8. Caseworker/Provider Assessment on Personal Functioning of the Youth (complete at initial placement only):
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

English Language Skill
Education (other than English)
Health Condition
Mental Health

Below
Above
Average
Excellent
Average
Average

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

1

2

3

4

5

Explain

9. URM's Children in Care:
First Name, Middle Name, Last Name

Date of Birth

Citizenship / Immigration Status

1st child
2nd child
3rd child
10. Mother of URM:
Last:

First:

a. Living:

Middle:

b. Mother's address when minor arrived in U.S.:
Yes
No
Unknown

c. Current Address:
Same as b. above

11. Father of URM:
Last:

First:

a. Living:

Middle:

b. Father's address when minor arrived in U.S.:
Yes
No
Unknown

c. Current Address:
Same as b. above

Section III: Immigration
1. Immigration
Refugee
Asylee
SIJ (I-360 approval)
Afghan Humanitarian Parolee
Cuban/Haitian Entrant-No immigration status
Ukrainian Humanitarian Parolee
2. Youth is receiving immigration assistance.
No
Yes

Victim of Trafficking-No immigration status (OTIP letter only)
U-Status Recipient
T-Status Recipient
Lawful Permanent Resident
Other:
* Change in immigration status may render a child no longer eligible for
URM. Consult ORR immediately with questions.

3. Youth has work authorization/Employment Authorization Document.
No
Yes
Section IV: Placement
1. Placement Type:
Foster Family Home
Therapeutic Foster Home
Group Home
Supervised Independent Living
Residential Treatment
Long-term hospitalization (more than 2 weeks)
Absent from program but legal responsibility retained
Living independently but receiving ORR-funded services/benefits
Other:

2. Placement Cost:

3. Youth's Residence:
Name:
Relation of caregiver:
Address:
City:
State:

4. Provider Agency for Placement:
Same as URM Provider
Placement via Subcontract

Zip:

(daily rate)

Name of Youth
First

Last

Alien Registration No.

HHS Tracking No.

Middle

Section V: Legal Responsibility
1. Legal responsibility has been petitioned.
Yes, it was petitioned within 30 days of enrollment.
Yes, it was petitioned past 30 days of enrollment.
No, it hasn't been petitioned.

Date:
Date:

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

No

Pending

2.a. In lieu of legal responsibility, youth has signed a Voluntary Placement Agreement.
Yes
Date:
No

N/A

3. Court name with jurisdiction:
4. Agency name to whom legal responsibility assigned:

5. Legal responsibility has ended.
Yes

Same as URM Provider

Date Ended
No

Section
VI:Agency
Report Submission Authority
1.
Provider
1. Provider Name
Address
City

State

Zip Code

User Name:

Title:

Phone:

Agency Approval Date:
(mm/dd/yyyy)

Email:
Secondary contact:

Title:

Phone:

Email:

2. State/URD Agency
Agency Name
Address
City

State

Zip Code

User Name:
Phone:

Title:

Agency Approval Date:
(mm/dd/yyyy)

Title:

ORR Approval Date:
(mm/dd/yyyy)

Email:

3. ORR
Name:
Approval/Denial Comments History:
In immediate response to priorities of the current administration, this form has been updated with the following changes prior to approval by the Office of Management and Budget
(OMB), as required by the Paperwork Reduction Act (PRA) of 1995 (44. USC. 3501 et seq.). The PRA requires that agencies obtain OMB approval before requesting information from the
public, and OMB review and approval for most changes to an approved information. ACF is working to process these changes through OMB to come into compliance with the PRA but has
implemented changes to the OMB-approved form to ensure compliance with the following Executive Orders: Executive Order(s) 14168 and/or 14151, 14173, 14224. Other than these
changes, this form is approved under OMB #: 0970-0034.