Form P-4 Notice of Placement in a Restrictive Setting (English)

OMB 0970-0554 [valid through MM/DD/20YY]

Administration for Children & Families

Office of Refugee Resettlement

Notice of Placement in a Restrictive Setting

You are in the custody of the Office of Refugee Resettlement (ORR), and have been placed in a restrictive setting (a secure or staff secure facility, or a residential treatment center) for the reasons listed below. If you have any questions about this placement, please discuss them with your case manager, your attorney, or an ORR-funded legal service provider.

Section A: UC Information

UC Full Name A# (no spaces)

Date of Birth Gender

Country of Birth Preferred Language

Care Provider Name Type of Facility

Out-of-Network Facility Name (if applicable)

If applicable, explain the reasons that the UC is placed in an out-of-network facility.

Date of Placement at Current Restrictive Facility

Date of Initial Notice of Placement

Date Next Notice of Placement is Due (within 30 days)

Section B: ORR's Determinations Related to Safety

UC presents a danger to self or community

UC poses a risk of escape

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to document and inform UC of the reason they have been placed in a restrictive setting. 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 (Flores v. Reno Settlement Agreement, No. CV85-4544-RJK (C.D. Cal. 1996)). 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. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov.

4. | Version 5 ^{Page 1 of 4}

Revised. MM/DD/2022

For each type of placement, check all reasons that apply for that placement only. Do not check reasons listed under a type of placement that is not applicable to the current facility.

Secure Facility

ORR has determined that you pose a danger to self or others; or have been charged with having committed a criminal offense. ORR considered that you:

Are charged with a crime, are chargeable with a crime, or have been convicted of a crime; or are the subject of delinquency proceedings, have been adjudicated delinquent, or are chargeable with a delinquent act¹

^{Have committed, or have made credible threats to commit a violent or malicious act while in ORR custody}

Have engaged in conduct that has proven to be unacceptably disruptive of the normal functioning of a staff secure facility in which you were placed such that transfer may be necessary to ensure your welfare or the welfare of others

^{Have self-disclosed violent criminal history prior to placement in ORR custody that requires further assessment}

Have committed sexual abuse², where there is coercion by overt or implied threats of violence against another person and/ or there is an immediate danger to others

^{Are pending transfer or discharge/release to: (no other option above should be checked)}

Residential Treatment Center (RTC)

ORR has determined that you have a serious psychiatric or psychological issue that cannot be addressed in an outpatient setting and you are a danger to self or others. A licensed psychologist or psychiatrist has indicated that you:

Have not shown reasonable progress in the alleviation of your mental health symptoms after a significant period of time in outpatient treatment.

Demonstrate behavior that is a result of your underlying mental health symptoms and/or diagnosis and cannot be managed in an outpatient setting;

Require therapeutic-based intensive supervision as a result of mental health symptoms and/or diagnosis that prevent you from independent participation in the daily schedule of activities;

Present a continued and real risk of harm to self, others, or the community, despite the implementation of short-term clinical interventions.

^{Are pending transfer or discharge/release to: (no other option above should be checked)}

Staff Secure Facility

ORR has determined that you require close supervision, but do not require placement in a secure care provider facility. ORR considers that you:

Have been unacceptably disruptive to the normal functioning of a shelter care facility such that transfer is necessary to ensure the welfare of others

Are an escape risk

Have displayed a pattern of severity of behavior, either prior to entering ORR custody or while in ORR care, that requires an increase in supervision by trained staff

Have non-violent criminal or delinquent history not warranting placement in a secure care provider facility, such as isolated or petty offenses

Are pending transfer or discharge/release to: (no other option above should be checked)

Case Manager Notes

Name Recommendation

Provide a detailed summary of specific incidents related to the reason(s) for restrictive placement you selected above.

Case Coordinator Notes

Name Recommendation

Provide a detailed summary of specific incidents related to the reason(s) for restrictive placement you selected above.

Federal Field Specialist Notes

Name ORR Overall Recommendation

Section E: Your Rights to Challenge Your Placement

Provide a detailed summary of specific incidents related to the reason(s) for restrictive placement you selected above.

ORR will review your placement, at a minimum, every 30 days to determine whether your placement in a restrictive level of care is still necessary.

You have the right to consult an attorney and/or a child advocate to assist you. This Notice of Placement will be provided to your attorney and/or child advocate automatically.

The Notice of Placement will also be provided to your parent or legal guardian, unless they cannot be reached, there is an important

reason not to share it with them for your own welfare, or you are age 14 years or older and you request they not receive it.

At any time after you receive this Notice of Placement, there are three ways you may request that ORR reconsider your placement in a restrictive setting:

• You may request a Placement Review Panel to reconsider your placement.

• You may ask a Federal District Court to review your case.

• You may request a bond hearing from an Immigration Judge to decide whether you are a danger to the community. However, the bond hearing outcome does not automatically change your placement.³

For more information on this process, please ask your case manager, attorney, or child advocate.

Section F: Acknowledgement and Certification

UC ACKNOWLEDGEMENT OF RECEIPT

UC's Signature/Mark ^Date

Please check this box ONLY if the child refused to sign the Notice of Placement.

CARE PROVIDER/ISSUING OFFICIAL CERTIFICATION

Care Provider/Issuing Official's Signature ^Date

Care Provider/Issuing Official's Name and Title

INTERPRETATION

This document was explained to the UC in

by , ID#

END NOTES

1. Excluding: isolated offenses that (1) were not within a pattern or practice of criminal activity and (2) did not involve violence against a person, or the use or carrying of a weapon (e.g., breaking and entering, vandalism, DUI, etc.); or petty offenses which are not considered grounds for a stricter means of detention in any case (e.g., shoplifting, joy riding, disturbing the peace, status offenses).

2. As defined by the Interim Final Rule on Preventing, Detecting, and Responding to Sexual Abuse, 45 CFR Part 411 and in UC Policy Guide Section 4.1.1 Sexual Abuse.

3. An immigration judge does not rule on any of the following: release to a sponsor; the unaccompanied child's placement or conditions of placement while in ORR custody; or releasing the child on his or her own recognizance (see UC Policy Guide Section

2.9 Bond Hearings for Unaccompanied Children).