Form ORR-3 Unaccompanied Refugee Minor Placement Report

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Form Approved

Office of Refugee Resettlement

OMB No. 0970-0034

Name of Youth:

Constance Combs: Entering either of these numbers will populate the name and information in the rest of the screens if case is in the system. Alien No.

HHS Tracking No.

Family

Middle

Given

UNACCOMPANIED REFUGEE MINOR

PLACEMENT REPORT

FORM ORR-3

Constance Combs: Selection from drop down menu populates agency address and contact information. State Agency

Agency Name

Street Address

City

State

Zip Code

Phone

Email

Section I. Report Action

o

Constance Combs: Selection sends user to blank Section II to initiate file record. Initial placement - Must be submitted within 30 days

o

Re-entered ORR-funded services

o

UAC transfer

o

Constance Combs: Selection sends user to appropriate section to complete. Foster care

o

Constance Combs: Selection sends user to related section to add/edit information. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change

o

Independent Living

o

Establishing/changing legal responsibility

o

Placement change/change in address

o

Change in placement cost

o

Constance Combs: Sends user to Section III to complete Change in immigration status

o

Constance Combs: Selection sends user to Section II to re-enter data. Change in identifying data,e.g., name, age redetermination, received A#

o

Constance Combs: Sends user to Section II to enter address information. Change in parents' location

o

Emancipated from foster care but receiving ORR-funded IL/education services

o

Constance Combs: Sends user to Section II to add child information Became a parent

o

Termination of ORR-funded services/Final Report:

o

Reunification with parent

o

Unification with:

o

Relative granted legal responsibility

o

Non-relative with legal responsibility

o

Adoption

o

Emancipation

o

Voluntary termination

o

Citizenship

o

Ran away

o

Constance Combs: Includes US citizenship Loss of eligibility

o

Immigration detention

o

Incarcerated

o

Deceased

o

Other

Explain destination/current situation at case closure.

Section II: Identifying Data

1. Sex:

2. Date of Birth

3. Date of Eligibility

o

Female

o

Male

4. Date of Initial Placement

5. Estimated Date of Emancipation:

6a. Country of origin:

7a. Language of origin:

6b. Ethnic group:

7b. Other language(s):

8. Eligibility Type:

9. Placement Type:

o

Refugee

o

Constance Combs: Indicate only if overseas case Overseas

o

Asylee

o

Entrant

o

Trafficking Victim

o

Special Immigrant Juvenile (SIJ)

o

Other

10. National Voluntary Agency

11. Parent of child

Name(s)

DOB

Citizen/Immigration status

o

1 child

o

2 children

Agency name

o

3 children

12. Mother's Name:

Family

Middle

Given

a. Living:

b. Mother's address when minor arrived in U.S.:

o

Yes

o

No

o

Unknown

c. Current Address:

13. Father's Name:

Family

Middle

Given

a. Living:

b. Father's address when minor arrived in U.S.:

o

Yes

o

No

o

Unknown

c. Current Address:

Section III: Immigration Status Data

Current Immigration Status/Situation

New Immigration Status/Situation

o

Refugee

o

Lawful Permanent Resident

o

Asylee

o

Asylee

o

SIJ (I-360 approval)

o

T-Visa

o

SIJS(I-485 approval)

o

U-Visa

o

Amerasian

o

Ordered Removed

o

Victim of Trafficking-No immigration status

o

Relief under Convention Against Torture

o

Victim of Trafficking with T-Visa

o

U.S. Citizen

o

Victim of Trafficking with U-Visa

o

SIJS (I-485 approval)

o

Cuban/Haitian Entrant-No immigration status

o

Parole

o

Lawful Permanent Resident

o

Revocation of trafficking eligibility letter

o

Parole

o

Other

o

Other

Change in immigration status may render a child no longer eligible for URM, particularly for Cuban/Haitian Entrants. Consult ORR. U.S. citizens are no longer eligible for URM.

Section IV: Foster Care Placement Data

1. Placement Type:

2. Placement Date:

o

Relative

o

Foster Care

3. Placement Cost:

o

Therapeutic Foster Care

$

(average daily rate)

o

Group Home

o

Semi-Independent Living

o

Independent Living

o

Residential Treatment

o

Inpatient psychiatric hospital

o

Other

4. Foster Parents/Youth's Relative:

Relation

Name:

Phone Number:

Address

5. Provider Agency for Placement:

Agency name

Phone Number:

Address

6. Medical Coverage:

o

Medicaid

o

RMA

o

Constance Combs: Selection moves user to "Other Coverage Provider" Other

If Other coverage provide name:

Section V: Legal Responsibility Data

1. Court with jurisdiction:

Date petition filed:

Date legal responsibility established:

Name

Address

2. Agency to whom legal responsibility assigned:

Name

Address

3. Has legal responsibility ended?

Date ended:

o

Yes

o

No

4. Voluntary Placement Agreement:

Date signed:

o

Yes

o

No

Section VI: Independent Living Data

Constance Combs: Complete if youth has emancipated from foster care and is no longer receiving "placement" services. 1. Youth residence:

Street Address

City

State

Zip Code

Phone

2. Service Type:

Select funding source

ORR

State/ Chafee

Private

o

a.

Educational benefits (Ed)

o

o

o

o

b.

Independent living (IL)

o

o

o

3. For all ORR-funded services, list provider:

Agency Name:

Contact Information:

a. Ed

b. IL

Section VII: Form Submission Authority

1. Unaccompanied Refugee Minor (URM) Provider Agency:

Agency Name

Street Address

City

State

Zip Code

Phone

Email

Signature of Person Preparing Form:

Date of signature:

Name

Title

2. State Agency:

Agency Name

Street Address

City

State

Zip Code

Phone

Email

Signature of State Official Submitting Form:

Date of signature:

Name

Title