Title ORR-3The Refugee Unaccompanied Minor Placement Report

DEPARTDMENT OF HEALTH AND HUMAN SERVICES Form Approved

Office of Refugee Resettlement OMB No. 0970-0309

REFUGEE UNACCOMPANIED MINOR PLACEMENT REPORT		Local Provider Agency Case No.
TO: Office of Refugee Resettlement U.S. Department of Health and Human Services 370 l'Enfant Promenade, S.W. Washington, D.C. 20447	FROM: Name
	Title:
	Agency:
	Address:
Change of Status Report - Action Taken: Placement Change Legal Responsibility Change DOB/Name Other__________________ Final Report - Action Taken: Is initial placement also a reclassification? Check the appropriate box: Parent/Relative Initial Placement Report Yes No Emancipation Reunification AWOL/Jail REPORT USAGE

Always complete Nos. 1,4 and 9 of Section I-A below, and other Sections as appropriate.

SECTION I - IDENTIFYING DATA

	1. Name of minor (Family - Middle - Given)	2. Date of birth (Mo. - Day - Year)	3. Sex	4. Alien No./HHS Tracking No.
I-A	5. Social Security No.	6. Date minor entered the U.S. (From I-94 form) or date on the ORR eligibility letter for trafficking minors, or from the Immigration Judge’s Order, if granted asylum.		7. Estimated Date for emancipation (Mo. - Year)
Refugee Asylee Entrant Trafficking Victim	8. Country of Origin	9. Status
Yes No	10. Mother's Name (Family - Middle - Given)			Living
	Residence when Minor Arrived in U.S.	Current Address
Yes No I-B	11. Father's Name (Family - Middle - Given)			Living
	Residence when Minor Arrived in U.S.	Current Address
	12. National Voluntary Agency

SECTION II - PLACEMENT DATA

1. Type of Placement Relative Independent Living Inpatient Psych. Hosp. Residential Treatment Foster Care Semi-Independent Group Home			2. Date of this Placement
Yes No 3. If foster care, are foster parents of same ethnic group or same linguistic background as minor:
4. If placed with relative, state relationship:	Name and Address	Phone No. (Include Area Code)

FORM ORR-3 (07/31/2009)

Page 1 (This form replaces ICPC 100B -- the Interstate Compact on the Placement of Children Initial Placement Form.)

DISTRIBUTION: White – Office of Refugee Resettlement - HHS; Canary – State Agency; Goldenrod – Originator; Pink – National Voluntary Agency

SECTION II - PLACEMENT DATA (Continued)		Alien No.
5.a Name and address of Foster Parent/s with whom minor was placed		Phone No. (Include Area Code)
5.b Name and address of Provider Agency with whom minor was placed		Phone No. (Include Area Code)
6. Name and address of Supervising State Child Welfare Agency		Phone No. (Include Area Code)
SECTION III - LEGAL RESPONSIBILITY DATA
1. Name and address of Court having jurisdiction over minor		2. Date court established legal responsibility for minor
3. Name and address of person/agency to whom legal responsibility assigned
SECTION IV - PROGRAM TERMINATION
1. Reason for program termination		Date of termination
2. Court determination upon program termination		Date of court action
3. Destination (including address) of minor upon program termination
SECTION V
Name and Signature of person preparing form	Date of Signature	Phone No. (Include Area Code)
Title

FORM ORR-3 (07/31/2009)

Page 2 (This form replaces ICPC 100B -- the Interstate Compact on the Placement of Children Initial Placement Form.)

DISTRIBUTION: White – Office of Refugee Resettlement - HHS; Canary – State Agency; Goldenrod – Originator; Pink – National Voluntary Agency