Form 1 ORR-5 (New January 2021)

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Overview

ORR-5 Sections I&II
ORR-5 Section III

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Sheet 1: ORR-5 Sections I&II

Refugee Data Submission System for Formula Funds Allocations and Service Analysis (ORR–5): Sections I & II

OMB #: 0970-0043

Expiration Date: XX/XX/XXXX

SECTION I: BASIC INFORMATION

SECTION II: RSS FAMILY SELF-SUFFICIENCY PLAN (FSSP) INITIAL ASSESSMENT AND REFERRAL

1. Alien Number

2. Principal Applicant (PA) Alien Number

3. Relationship to PA

4. First Name

5. Middle Name

6. Last Name

7. DOB

8. Status or Category

9. Gender

10. Nationality

11. Zip Code

12. City

13. County

14. Eligibility Date

15. Migration Status

16. Date of Migration

17. Refugee Cash Assistance (RCA) Enrollment Date

18. RCA Exit Date

19. Refugee Medical Assistance (RMA) Enrollment Date

20. RMA Exit Date

21. Medical Screening Enrollment Date

22. Medical Screening Exit Date

23. Refugee Support Services (RSS) Enrollment Date

24. RSS Exit Date

25. RSS FSSP English Ability

26. RSS FSSP Education Level

27. RSS FSSP Initial Primary Goal (G1)

28. RSS FSSP Initial Referral Relevant to G1

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client goals, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making, and data collected in section I will guide resource allocation. Public reporting burden for this collection of information is estimated to average 140 hours per grantee, 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 [Immigration and Nationality Act, section 412(a)(3)]. 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 draprograms@acf.hhs.gov.

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Sheet 2: ORR-5 Section III

			Refugee Data Submission System for Formula Funds Allocations and Service Analysis (ORR–5): Section III						OMB #: 0970-0043
									Expiration Date: XX/XX/XXXX
SECTION III: RSS FSSP 12-MONTH FOLLOW-UP
29. Refugee Arrivals Data System (RADS) Case ID	30. RADS Individual ID	31. Alien Number	32. RSS FSSP Initial Primary Goal Met?	33. RSS FSSP Employment Status	34a. RSS FSSP Total Number of Months Employed Full-Time	34b. RSS FSSP Total Number of Months Employed Part-Time	34c. RSS FSSP First Employment Date	34d. RSS FSSP Best Hourly Wage	35. RSS FSSP How Was 12-Month Follow-Up Information Collected?
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client goals, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making, and data collected in section I will guide resource allocation. Public reporting burden for this collection of information is estimated to average 140 hours per grantee, 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 [Immigration and Nationality Act, section 412(a)(3)]. 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 draprograms@acf.hhs.gov.