Form ORR-3 Status Added

DEPARTMENT OF HEALTH AND HUMAN SERVICES

Office of Refugee Resettlement

Name of Youth

Alien Registration No.

HHS Tracking No.

Last

First

Middle

ORR-3 FORM

UNACCOMPANIED REFUGEE MINOR

PLACEMENT REPORT

State Agency

URM Provider Agency

Agency Name:

Agency Name:

Street Address:

Street Address:

City:

City:

State:

Zip

State:

Zip:

National Voluntary Agency

USCCB

LIRS

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)

Date of Action(M/D/Y)

Establishing/changing legal responsibility

Transfer to/from another URM Program

Change in placement

Change in placement cost

Change in immigration/eligibility data

Change in biological parent's location

Absent from program but legal custody retained

Emancipated from placement services but receiving ORR-funded IL/education services

Became a parent

Change in identifying data,e.g., age redetermination, name, received A#,

or development of a safety plan.

Explain "Change of Status" if necessary

3. Termination of ORR-funded services/Final Report:

Date of Termination:

Reunified with Parents:

Dismissed from Program

within the US

Ran Away

Overseas

Departure from US:

Removal

Relative Granted Legal Responsibility

Voluntary Departure

Non-relative Granted Legal Responsibility

Loss of Eligibility

Emancipation

Immigration Detention

with state/Chafee-funded IL/Education services

Incarcerated

Conclusion of ORR-funded IL/Education services

Deceased

Voluntary Termination

Other

Explain destination/current situation at case closure.

4. Re-entered ORR-funded placement and/or services

URM Placement

Independent Living Services

Section II: Identifying/ Basic Data

1. Sex:

2. Date of Birth

3. Date of Eligibility

4. Date of Initial Placement

Female

Male

5a. Est. Emancipation from Placement

5b. Est. Date of Termination from ORR-funded IL/Edu. Services

6a. Country of Origin:

6b. Ethnic Group:

7a. Language of Origin:

7b. Other Language(s):

8. Eligibility Type:

Refugee

Asylee

Entrant

U Status Recipient

Trafficking Victim

Special Immigrant Juvenile (SIJ)

Other

9.Has a safety plan been developed?

Yes

No

Not applicable

10. URM's Children in Care:

Name(s)

DOB

Citizenship/Immigration Status

1 child

2 children

3 children

11. Mother of URM:

Last

First

Middle

a. Living:

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

Yes

No

c. Current Address:

Unknown

12. Father of URM:

Last

First

Middle

a. Living:

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

Yes

No

c. Current Address:

Unknown

Section III: Immigration/ Eligibility Data and Immigration Assistance

1. Immigration/ Eligibility Data

U Status Recipient

Refugee

Cuban/Haitian Entrant-No immigration status

Asylee

Parole

SIJ (I-360 approval)

U.S. Citizen

Amerasian

Ordered Removal

Victim of Trafficking-No immigration status

Relief under Convention Against Torture

Victim of Trafficking with T Status

Deferred Action

Victim of Trafficking with U Status

Revocation of Trafficking Eligibility Letter

Legal Permanent Resident

with Immigration Status

Other

2. Is youth receiving immigration assistance?

Yes

No

NA

Pro bono attorney

* Change in immigration/eligibility data may render a child no longer eligible for URM, particularly for Cuban/Haitian Entrants. Consult ORR.

Pro bono accredited representative

Social or legal service agency

* URMs who become U.S. citizens are no longer eligible for URM.

Other:

Section IV: Placement Data

1. Placement Type:

2. Placement Cost: $

(average daily rate)

Relative Foster Care

Foster Care

Therapeutic Foster Care

Group Home

Semi-Independent Living

Residential Treatment

Inpatient psychiatric hospital

No Placement (enter youth living independently in Sec. IV: IL Residence and Services)

Other

3. Caregiver Residence

4. Provider Agency for Placement:

Name:

Name:

Relation if caregiver:

Address:

Address:

City:

City:

State:

Zip:

State:

Zip:

Section V: Legal Responsibility Data

1. Court with Jurisdiction:

Date Petition Filed:

Date Legal Responsibility Est.:

Name:

Address:

City:

State:

Zip Code:

2. Agency to Whom Legal Responsibility Assigned:

Name:

Address:

City:

State:

Zip Code:

3. Has Legal Responsibility Ended?

Date Ended

Yes

No

4. Voluntary Placement Agreement:

Date Signed

Yes

No

Section VI: Independent Living Residence and Services

1. Youth residence:

Address:

City:

State:

Zip Code:

2. Independent Living - URM placement has ended

Yes

Stipend Amount (monthly rate):

$

3. Independent Living Services:

Select Funding Source

ORR

State/ Chafee

Private

Other

a. Educational benefits (Ed)

b. Independent living (IL)

Section VII: Form Submission Authority

1. Unaccompanied Refugee Minor (URM) Provider Agency:

Agency Name:

0

Address:

0

City:

0

State:

0

Zip Code:

00000

Name

Title

Date

Phone:

Email:

2. State Agency:

Agency Name:

0

Address:

0

City:

0

State:

0

Zip Code:

00000

Name

Title

Date

Phone:

Email: