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ORR 4 Report Form_2026 (2 Years Implementation)
ICR 202610-0970-002 · OMB 0970-0034 · Object 173984200.
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| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
|---|---|
| File Title | ORR 4 Report Form_2026 (2 Years Implementation) |
| Author | Wasik, Heather (ACF) |
| Last Modified By | Writer |
| File Modified | 2026-10-07 |
| File Created | 2026-10-21 |
| Conversion State | complete |
Extracted Text
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/replacement designee agencies and .60 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 XX/XX/XXXX. If you have any comments on this collection of information, please contact the ORR URM Program at [email protected]. ORR-4 Report Form Unaccompanied Refugee Minors (URM) Program Name of Youth Alien No. HHS Tracking No. Last: (auto populates-not editable) First: (auto populates-not editable) Middle: (auto populates-not editable) (auto populates-not editable) (auto populates-not editable) State/URD Agency URM Provider Agency Agency Name: (auto populates-not editable) Agency Name: (auto populates-not editable) Address: (auto populates-not editable) Address: (auto populates-not editable) City: (auto populates-not editable) City: (auto populates-not editable) State: (auto populates-not editable) Zip: (auto populates-not editable) State: (auto populates-not editable) Zip: (auto populates-not editable) The ORR-4 supplemental instructions should be consulted while completing this form. The supplemental instructions are available on ORR’s website: https://acf.gov/orr/form/report-forms. SECTION I: REPORT ACTION • 1. Annual Outcomes Report: Due to ORR annually within 60 calendar days of and not prior to the anniversary of the youth’s Initial Placement date. • 2. Termination Outcomes Report: Due to ORR within 60 calendar days of the youth’s termination date. Youth’s Initial Placement Date (auto populates-not editable) Youth’s Most Recent Termination Date (auto populates-not editable) SECTION II: SERVICE AND BENEFIT RECEIPT Indicate if the youth received the following services or benefits at any point during the reporting period. Select “Yes” if a service/benefit was provided during the reporting period, regardless of duration. Many services/benefits captured in this report are not ORR/URM Program-funded, select from the three different “Yes” options to indicate funding source. If a service/benefit was free, select “Yes: Not funded by ORR/URM.” Select “No” if the youth did not receive the service/benefit during the reporting period. Select whether the youth did not receive the service/benefit because the youth did not need it OR if the youth did not receive the service/benefit and needed it. See the ORR-4 supplemental instructions for examples and for an explanation on reporting periods. Service/Benefit Definition Response English Language Skills 1. English language learner services Instruction to improve English language proficiency. Services are formally arranged, may be offered within or outside of a school setting, synchronous or asynchronous, fee-based or free. Services do not include informal conversation partners or social groups with whom the youth practices their English skills. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Education & Employment 2. Specialized school-based academic services Specialized instruction, services, and/or accommodations the school provides, in addition to general education, to meet academic goals. These services (e.g., 504 plans, Individualized Education Plans, etc.) are school-based, formally arranged, and documented in the youth’s school record. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 3. Academic tutoring services Instruction to improve academic performance other than English language proficiency (captured above). Services are formally arranged, may be offered within or outside of a school setting, synchronous or asynchronous, fee-based or free. Services do not include informal support or assistance with coursework. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 4. Post-secondary education support and/or vocational training services Services or training to build skills or prepare for enrollment in education after high school or a vocational training program, such as test preparation courses, admissions counseling, support with applications, etc. These support services may be informal and do not include payments, stipends, or funds to enroll in or apply for school (see instead #5 and #6). Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 5. Education and Training Vouchers (ETV) State-administered, Chafee/Chafee-comparable funds for education after high school and/or vocational training programs that are available to youth in or formerly in foster care. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 6. Education benefits Financial assistance to pay for education after high school and/or a vocational training program. This may be public or private funding, but does not include ETVs (see instead #5) Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 7. Employment and workforce preparation services Services and training to learn how to find and maintain work, including paid work, internships, apprenticeships, etc. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Health 8. Health education Services to learn about personal and community health and safety including disease prevention, insurance coverage options, when and how to schedule medical appointments, filling prescriptions, first aid, hygiene, nutrition, exercise, etc. These services may also include psychoeducation related to interpersonal skills, healthy relationships, boundaries, and emotional well-being. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 9. Physical health care services Direct health care services to prevent and/or treat physical illness (e.g., annual physical, prescription medications, hospitalization, urgent care or emergency room visits, dental care, vision care, etc.). Licensed medical practitioners provide these services. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 10. Mental health care services Direct mental health care services to prevent and/or treat psychiatric illness (e.g., psychotherapy, psychotropic medications, mental health crisis response, psychiatric hospitalization, etc.). Licensed mental health practitioners provide these services. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Social and Family Connections 11. Ethnic, cultural, and/or religious services Services to facilitate engagement in and preservation of cultural, ethnic, and religious identity. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 12. Family reunification services Services to legally reunite a minor child with his/her parent or legal custodian. For the purposes of this report, receipt of these services indicates the custodian was engaged with the URM provider agency and demonstrating efforts to obtain full responsibility of the child’s care and well-being. If youth is currently aged 18 or older, select “No: Did not need it.” Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 13. Parenting skills training Services to learn child rearing skills and how to safely care for his/her dependent children. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 14. Mentoring services Services to guide and advise on social, educational, and personal decisions, as well as promote prosocial behavior. Community members, outside of URM provider agency staff and foster parents, provide mentoring services. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Financial 15. Financial literacy training Services and training to learn financial management skills (e.g., budgeting, banking, credit, loans, taxes, etc.). Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 16. Public benefits Government-funded assistance to foster economic self-sufficiency, such as Supplemental Nutrition Assistance Program (SNAP), Supplemental Security Income (SSI), Child Care Scholarship (CCS) and subsidies, and Temporary Assistance for Needy Families (TANF). These benefits are never funded by ORR/URM. Exclude assistance for health care, education, or housing in this response. Exclude foster care stipends and/or Chafee or Chafee-comparable funding. Drop-down: • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Transition to Adulthood Services 17. Chafee or Chafee-comparable services Services and funding to promote a successful transition to adulthood (e.g., housing assistance, education assistance, transportation, job training, etc.). It is acceptable to report receiving services/benefits for housing, education, transportation, job training, etc. both here and in other service/benefit questions. However, do not include receipt of ETVs here (see instead #5). Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Housing 18. Housing education or home management services Services and training to understand how to find and maintain housing (e.g., reading/signing rental agreements, understanding security deposits, etc.) and learn home safety skills (e.g., safe food preparation, housekeeping, basic home maintenance, etc.). These services do not include stipends or funds for housing (see instead #19-21) Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 19. Housing financial assistance Financial assistance to pay for housing, including foster care room/board stipends and/or housing stipends through Chafee/Chafee-comparable funding. Exclude public housing assistance (see instead #20) and vouchers (see instead #21). Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 20. Public housing Government-funded assistance to obtain public housing. “Public Housing” is rental housing managed by a local housing authority and administered by the U.S. Department of Housing and Urban Development (HUD) to families whose incomes are below the federal poverty threshold, people aged 62 and older, and people with disabilities. Exclude foster care room/board stipends and/or Chafee or Chafee-comparable funding for housing (see instead #19). This benefit is never funded by ORR/URM. Drop-down: • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 21. Housing choice voucher “Housing Choice Voucher” is a rental housing subsidy administered by a local public housing authority and funded by HUD. This benefit is never funded by ORR/URM. Drop-down: • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Transportation 22. Transportation services Services to physically transport a youth to appointments, activities, work, or other engagements. This includes providing private transportation, bus/train fares or passes, bicycles, supplies or materials for other modes of transportation. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it 23. Transportation skills training Services and training to learn how to access and navigate transportation such as how to use public transit, bicycling safety, driver’s education, driving rules and laws, etc. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it Immigration 24. Immigration services Services to coordinate to meet the youth’s needs related to immigration status. This includes referrals for immigration legal representation, transporting the youth to/from immigration appointments, helping the youth complete a form, etc. Drop-down: • Yes: Funded only by ORR/URM • Yes: Funded by ORR/URM and other sources • Yes: Not funded by ORR/URM • No: Did not need it • No: Needed it SECTION III: OUTCOMES See the ORR-4 supplemental instructions for an explanation on reporting periods. English Language Skills 1. English Interpretation Needs: Does the youth require an interpreter for conversations in English? • Yes, all conversations • Yes, only complex or technical conversations • No 2. English Translation Needs: Does the youth require translation for documents written in English? • Yes, all documents • Yes, only complex or technical documents • No Education & Employment 3. Education Completed within the United States: Select the highest level of education the youth completed within the United States by the end of the reporting period. Select the highest level completed regardless of whether the education was completed prior to or during the reporting period: • Never completed any formal education in the United States • Preschool-5th grade • 6th-8th grade • 9th-11th grade • High school diploma (completed 12th grade) or GED • Post-secondary vocational/trade/certificate program • Associate’s degree • Bachelor's degree • Master’s degree • Doctorate 4. Education Enrollment: Select the level of education the youth was enrolled in on the last day of the reporting period. For reporting purposes, a youth is still considered enrolled in school even if that school is currently on break; select the grade the youth will be enrolled in when school resumes after break. • Not enrolled in school on the last day of the reporting period • Preschool-5th grade • 6th-8th grade • 9th-12th grade • GED program • Post-secondary vocational/trade/certificate program • Associate’s degree program • Bachelor's degree program • Master’s degree program • Doctoral program 5. Social Security Card: Select whether the youth had been issued a social security card by the last day of the reporting period. • Yes • No 6. Work Authorization: Select whether the youth was legally authorized to work in the United States on the last day of the reporting period. Select “Yes” or “No” based on if the youth was legally authorized to work in the United States. Some youth have work authorization incident to their immigration status and may not have a physical Employment Authorization Document (EAD). Answer the question based on whether the youth is legally authorized to work, not if the youth has a physical EAD card. • Yes • No 7. Employment Status: Select the youth’s employment status on the last day of the reporting period. • Employed full time (at least 35 hours/week) • Employed less than full time • Not employed Health 8. Health Insurance: Did the youth have health insurance on the last day of the reporting period? “Health Insurance” includes public- (government) or private-funded health coverage, such as Medicaid, CHIP, ORR-funded Medical Assistance, public option, or private insurance. Note: ORR-funded Medical Assistance is health coverage paid for by ORR/URM funds, regardless of the vehicle (e.g., Medical Replacement Designee, Marketplace, state workaround, or any other public/private option). • Yes, through ORR-funded Medical Assistance • Yes, through a source other than ORR-funded Medical Assistance (e.g., Medicaid, CHIP, public option, private insurance, etc.) • No As of the final day of the reporting period, how well can the youth independently manage and navigate his/her… Definition 1: Never able 2: Rarely able 3: Sometimes able 4: Frequently able 5: Always able 9. Physical health needs Youth’s ability to schedule and attend necessary doctor appointments, fill prescription medication, take medication as prescribed, know what to do in event of medical emergency, etc. to meet his/her individual physical health needs. 10. Mental health needs Youth’s ability to schedule and attend mental health appointments, fill psychotropic medications, take medication as prescribed, know what to do in event of a psychiatric crisis/emergency, etc. to meet his/her individual mental health needs. Social and Family Connections 11. Children: Does the youth have any children? • Yes • No 11a: If yes, enter the number of children, based on where the child(ren) reside: • Number of children who do not reside with the URM youth: ____ • Number of children who reside with the URM youth: _____ 11b: If any children reside with the URM youth, were any of these children born during the reporting period? • Yes • No 11c: If yes, provide each child’s information below. Hit the “Add row” button if you need to report more than one child. Dependent’s First Name, Middle Name, Last Name Dependent’s Date of Birth Dependent’s Citizenship Status If not citizen: Dependent’s Alien Number (calendar field) • U.S. Citizen • Not U.S. Citizen +Add rows 12. Family Contact: Did the youth maintain contact with at least one family member during the reporting period? • Yes • No • Unknown 13. Adult Connection: Is there currently at least one adult in the youth’s life, other than his/her case worker, to whom the youth can go for advice or emotional support? • Yes • No • Unknown 14. Peer Connection: Is there currently at least one peer of appropriate age in the youth’s life to whom the youth can go for advice or emotional support? • Yes • No • Unknown Financial, Housing, and Transportation As of the final day of the reporting period, how well can the youth independently manage and navigate his/her… Definition 1: Never able 2: Rarely able 3: Sometimes able 4: Frequently able 5: Always able 15. Financial needs Youth’s ability to manage his/her finances, including budgeting, banking, credit, loans, taxes, knowledge of available financial assistance, and enrolling in eligible financial assistance, etc. to meet his/her individual financial needs. 16. Housing needs Youth’s ability to manage his/her housing needs, including finding and keeping housing, maintaining a safe home, knowledge of housing available housing assistance, and enrolling in eligible assistance to meet his/her individual housing needs. 17. Transportation needs Youth’s ability to manage his/her transportation needs including accessing and navigating transportation, purchasing and maintaining transportation methods, knowledge of driving or other transportation skills, and staying safe to meet his/her individual transportation needs. Immigration 18. Immigration Status/Classification: Select the youth’s immigration status/classification as of the final day of the reporting period: • Lawful Permanent Resident • Refugee • Asylee • U-Status Recipient • T-Status Recipient • Afghan Humanitarian Parolee • Ukrainian Humanitarian Parolee • Special Immigrant Juvenile classification (I-360 approval) • Cuban/Haitian Entrant-No immigration status • Victim of Trafficking-No immigration status (OTIP letter only) • Other:______________________________ SECTION IV: REPORT SUBMISSION AUTHORITY 1. Provider Agency Agency Name: (auto populates-not editable) State: (auto populates-not editable) Address: (auto populates-not editable) Zip Code: (auto populates-not editable) City: (auto populates-not editable) Name: Title: Phone: Email: Secondary Contact: Title: Phone: Email: 2. State/ URD Agency Agency Name: (auto populates-not editable) State: (auto populates-not editable) Address: (auto populates-not editable) Zip Code: (auto populates-not editable) City: (auto populates-not editable) Name: Title: Phone: Email: 3. ORR Name: Title: Approval/Denial Comments History: (Display of report submission and approval dates automatically generated from system.)