Form ORR-4 Form ORR-4 Form ORR-4 Form

DEPARTMENT OF HEALTH AND HUMAN SERVICES

OMB No. 0970-0034

Office of Refugee Resettlement

Exp. XX/XX/XXXX

Name of Youth

Alien Registration No.

HHS Tracking No.

Last

First

Middle

ORR-4 REPORT FORM

UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM

OUTCOMES REPORT

State/ URD Agency

Provider Agency

Agency Name:

Agency Name:

Address:

Address:

City:

City:

State:

Zip:

State:

Zip:

Section I: Report Action

1. Annual Outcomes Report

2. Follow-up Annual Report: Former URM clients who are 17 to 21 years old and have terminated all ORR-funded services. Proceed to Section VI. Outcomes.

Date data was collected

(mm/dd/yyyy)

Age

Section II: Identifying Data

1. Date of Birth

2. Sex

Female

Male

Section III: Education and Personal Functioning of the Youth

1. Education Information:

a.

Most Recent Education and Grade Level, if applicable

Regular Mainstream School

Alternative to High School

Less than 6th grade

9th grade

6th grade

10th grade

7th grade

11th grade

8th grade

12th grade

9th grade

Dual-credit program

10th grade

No Grade Assigned

11th grade

12th grade

Trade/Vocational program

Job Corps/Job Corps equivalent

Post-secondary education

Not in school

Provide additional information.

b.

Youth is receiving English Language Learner (ELL) support.

Yes

No

2. Caseworker/Provider Assessment:

Assess the youth's functioning in the following areas at an age-appropriate level on a scale of 1 through 5, as indicated below. Provide an explanation if necessary.

Poor

Below Average

Average

Above Average

Excellent

Explain

English Language Skill

2

Education (other than English)

2

3

4

5

Social Adjustment

2

Health Condition

2

3

4

5

Mental Health

1

2

3

4

5

Preservation of Ethnic and Religious Heritage

2

Readiness to Live Independently

2

Section IV: Family Reunification

1. The youth has a permanency plan.

Yes

No

a. The youth's most recent primary permanency goal was:

Adoption

Guardianship

Reunification

Another Planned Permanent Living Arrangement (APPLA)

Permanent Placement with Fit and Willing Relative (PPFWR)

2. Family reunification efforts in the reporting period

a. Parents or relatives in the U.S. have been (re-)assessed for reunification.

Yes

No

b. There have been significant developments in reunification efforts.

Yes

No

If Yes, describe efforts and significant developments:

c. There has been a decision to not reunify the youth with a parent or relative.

No

If Yes, explain any such decisions; include relationship(s) and reason(s) for not reunifying youth.

3. There have been family tracing efforts with parents or relatives in other countries for the purpose of reunification.

Yes

No

If Yes, describe family tracing efforts.

Section V: Transition to Adulthood Services

1. Youth's residence:

Address:

City:

State:

Zip:

2. Service Type(s):

Yes

No

a. Youth remains in foster care

b. Post-adjudication juvenile probation

c. Special education

d. Independent living needs assessment

e. Academic support

f. Post-secondary educational support

g. Career preparation

h. Employment programs/vocational training

i. Budget & financial management

j. Housing education & home management training

k. Health education & risk prevention

l. Family support & healthy marriage education

m. Mentoring

n. Supervised independent living

o. Room & board financial assistance

p. Education financial assistance

q. Other financial assistance

Type:

Section VI: Outcomes

1. Outcomes reporting status:

2. Date of outcome data collection:

(mm/dd/yyyy)

a. Youth participated

b. Youth declined

c. Incapacitated

d. Incarcerated

e. Runaway/missing

f. Unable to locate or invite

g. Death

Data Elements

Queries

Responses

Yes

No

Declined

Don’t Know

3. Foster care status

Youth remains in foster care

4. Current full-time employment

Are you currently employed full-time?

5. Current part-time employment

Are you currently employed part-time?

6. Employment-related skills

In the past year, did you complete an apprenticeship, internship or other on the job training, either paid or unpaid?

7. Social Security

Are you currently receiving SSI, Disability or other dependents' payments?

8. Educational aid

Are you currently using a scholarship, grant, stipend, student loan, voucher or other education financial aid to cover educational expenses?

9. Public financial assistance

Are you currently receiving ongoing welfare [State TANF] payments to support your basic needs?

10. Public food assistance

Are you currently receiving public food assistance [SNAP or community program]?

11. Public housing assistance

Are you currently receiving any sort of public housing assistance?

12. Other financial support

Are you currently receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment?

13. Highest educational certification received

What is the highest educational degree or certification that you have received?

a. GED

b. high school diploma

c. vocational certificate

d. vocational license

e. associate's degree

f. bachelor's degree

g. higher degree

h. none of the above

i. declined

14. Current enrollment and attendance

Are you currently enrolled in and attending high school, GED classes, post-high school vocational training or college?

15. Connection to adult

Is there currently at least one adult in your life, other than your caseworker to whom you can go for advice or emotional support?

16. Homelessness

Have you ever been homeless at any time?

17. Substance abuse referral

Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling?

18. Incarceration

Have you ever been confined in a jail or other correctional facility or juvenile detention in connection with allegedly committing a crime?

19. Children

Have you ever given birth or fathered any children that were born?

20. Marriage at child's birth

If yes, were you married to the child's other parent at the time?

21. Medicaid

Are you currently on Medicaid [or use the name of the State's medical assistance program under title XIX]?

22. Other health insurance coverage

Do you currently have health insurance other than Medicaid?

23. Health insurance type: Medical

Does your health insurance include coverage for medical services?

24. Health insurance type: Mental health

Does your health insurance include coverage for mental health services?

25. Health insurance type: Prescription drugs

Does your health insurance include coverage for prescription drugs?

26. Health insurance type: Other

Does your health insurance include coverage for other services, e.g., dental or vision

Other type of coverage:

Section VII: Report Submission Authority

1. Provider Agency

Agency Name:

Address:

City:

State:

Zip Code:

User Name:

Title:

Date: (mm/dd/yyyy)

Phone:

Email:

2. State/ URD Agency

Agency Name:

Address:

City:

State:

Zip Code:

User Name:

Title

Date: (mm/dd/yyyy)

Phone:

Email:

3. ORR

Name:

Title:

ORR Approval Date:

(mm/dd/yyyy)

Approval/Denial Comments History: