Form 1 Placement Authorization Form

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services
OFFICE OF REFUGEE RESETTLEMENT
Division of Children’s Services
PLACEMENT AUTHORIZATION

The U.S. Department of Health and Human Services (HHS), Office of Refugee Resettlement (ORR), Division of Children’s
Services (DCS) is responsible for coordinating and implementing the care and placement of (6 U.S.C. 279 (b)(1)(A)):
Minor's Name:

Alien Number:

Date of Birth:

Nationality:

Hereby authorizes, hereinafter “care provider,” to provide 24 hour care for the minor. Care and placement will include, but is not
limited to:
1. Custody.
The minor is in the legal custody of the Federal government and is placed in the care provider’s physical custody for care and
shelter. The care provider must provide for the minor’s daily care and protection, which conforms to all applicable ORR
instructions and minimum standards based in statute or law. The minor’s placement with the care provider is based on the care
provider’s compliance with the requirements set forth in the contract or cooperative agreement with ORR. ORR, at its sole
discretion, may remove the minor from the care provider at any time.
2. Authority.
The care provider will adhere to all Federal and State licensing laws, rules, and regulations. Additionally, the care provider will
adhere to all ORR policies, guidance, and instructions. Failure to adhere to State licensing or ORR requirements will result in
corrective action up to and including termination of the grant or contract.
3. Education.
The care provider must enroll the child in an educational program(s) as directed by ORR. This may include educational
programming created by the care provider if approved by ORR. The care provider may sign any documents needed to enroll the
child in an educational program. The care provider may also receive and review all of the minor’s educational records.
4. Travel.
The care provider may provide routine transportation for the minor, including transportation to and from medical, mental, and
dental care; court hearings; transfer to other care provider programs; trips, outings, or other travel pertinent to the minor’s
educational, social, and emotional development.
5. Photographs and Videotapes.
The care provider may take photographs and record videotapes of the minor for the minor’s personal use and for purposes of
identification. The care provider may not release any photographs or videotapes of the minor for public use without ORR’s prior
written permission.
6. Medical Care.
The care provider may consent to the child’s medical, dental, and mental health care as specified in the Authorization to
Consent to Medical, Dental, and Mental Health Care. The care provider may receive, review, and maintain all of the minor’s
medical, dental, and mental health records in a separate medical file.
7. Files/Confidentiality.
All records maintained by the care provider in reference to the minor are considered ORR property. Under penalty of law, the
care provider must not release information about the minor to any individual, organization, or entity without the prior

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to
average .10/ hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the
collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it
displays a currently valid OMB control number.

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX

U.S. Department of Health and Human Services

• The care provider may provide information about the minor to the minor’s educational program, medical,
mental health, dental, and other service providers to the extent that the information is needed for the minor’s
education, recreation, social development, medical, dental, or mental health treatment.
• The care provider must give ORR and its designees, as directed by ORR, unrestricted free access to information
about the minor at all times.
• All case file information maintained under grants or contracts with the Federal government are the property of
the Federal government and are fully accessible to ORR/DCS, or any of their duly authorized representatives, in
accordance with applicable federal law, regulations, and OMB circulars. The records should be retained in
accordance with these applicable laws, regulations, OMB circulars, and ORR policies.
8. Contact with the Family.
The care provider must permit the minor and the minor’s family (as well as other individuals at ORR’s discretion) to
maintain contact through direct visitation, telephone calls, mail, and gifts under the terms and conditions specified by
applicable law, regulations, and ORR policies.
9. School Programs and Extracurricular Activities.
The care provider may authorize the minor to participate in routine school programs as well as social and
extracurricular activities that do not involve an unusual risk of injury to the minor unless otherwise specified by ORR.
10. Reason for Placement.
An unaccompanied minor who meets the definition of an unaccompanied alien child, 6 U.S.C. 279 (g)(2), and is in
Federal custody by reason of his or her immigration status.
11. Time in Care.
The care provider’s care giving authority will terminate upon the minor’s physical discharge from the care provider’s
custody. The care provider will still have legal obligations for maintaining the minor’s property if it is still in the care
provider’s custody and case file as directed by ORR.
12. Financial.
ORR agrees to provide financially for the care of said minor according to the financial agreement between ORR and
care provider or subsequent agreements agreed to by ORR and the care provider.
13. Restraints.
The care provider must exhaust preventive, de-escalative, and less restrictive techniques before it uses any type of
restraint. Should physical restraint be necessary for the safety of the minor or others, the care provider must use
behavior intervention techniques approved by ORR. All use of restraints must be justified and documented.

__________________________________________
Signature - Authorized Representative of Care Provider

_________
Date

________________
Telephone Number

__________________________________________
Signature - Official Representative
Office of Refugee Resettlement
Administration for Children and Families
US Department of Health and Human Services

_________
Date

________________
Telephone Number

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated
to average .10/ hour per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of
information unless it displays a currently valid OMB control number.