R-2 Discharge Notification

OMB 0970-0552 [valid through MM/DD/YYYY]

Administration for Children & Families

Office of Refugee Resettlement

Discharge Notification

UC Basic Information

Photo of Child [auto-populated]	First Name: [auto-populated]	AKA: [auto-populated]
	Last Name: [auto-populated]	Status: [auto-populated]
	Date of Birth: [auto-populated]	Admitted Date: [auto-populated]
	A#: [auto-populated]	Length of Stay: [auto-populated]
	Country of Birth: [auto-populated]	Current Program: [auto-populated]
	Gender: [auto-populated]	Portal ID: [auto-populated]

Discharge Notification

Date of Discharge: [date picker]	Time of Discharge: [text box]
Discharge Type: [dropdown] Reunified (Individual Sponsor) Reunified (Individual Sponsor) – Court-Ordered Reunified (Individual Sponsor) – Immigration Relief Granted Transfer of Placement Age Out Age Redetermination Voluntary Departure Child Deceased Determined to be U.S. Citizen Discharged to Program/Facility Discharged to Program/Facility – Court-Ordered Discharged to Program/Facility – Immigration Relief Granted Government Agency Joint Removal with Parent (VD Order for UC) Joint Removal with Parent (NTA Cancelled) Ordered Removed Ran Away from Facility Ran Away on Field Trip Referral Cancelled – OCONUS Age Out Referral Cancelled by Referring Agency UC Child Discharged with UC Parent U.S. Citizen Child Discharged with UC Parent Other	Sponsor Name: [dropdown]
Sponsor DOB: [auto-populated]	Relationship to UC: [auto-populated]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]
Primary Phone: [auto-populated]	Backup Phone Number: [auto-populated]

ORR Decision from Latest Release Request

ORR Decision: [auto-populated]
ORR Decision after Home Study: [auto-populated]
Updated Date/Time: [auto-populated]

Transfer of Placement

Receiving Program Name: [auto-populated]	Phone: [text box]
Address: [auto-populated]	City: [auto-populated]
State: [auto-populated]	Zip Code: [auto-populated]
UC Legal Status: [dropdown] NTA (in removal proceedings) Without status SIJS: I-360 approved SIJS: I-485 approved LPR derivative (of U.S. relative) LPR other Asylum: Immigration Judge Initial Order w/ 30-day appeal period Asylum: Immigration Judge Final Order w/ 30-day appeal period waived or completed Asylum: Appealed to federal court Asylum: USCIS grant U.S. Citizen Temporary Protected Status T-nonimmigrant status U-nonimmigrant status Other non-immigrant visa F-1 student visa (non-immigrant status) B-1/2 Tourist/business visa (non-immigrant status) Continued Presence Withholding of Removal Humanitarian Parole Final Order of Removal Other

Other Type of Discharge

Discharged into Custody of: [dropdown] Individual Program/Facility	Individual or Program/Facility Name: [text box]
Address: [text box]	City: [text box]
State: [text box]	Zip Code: [text box]

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 process the physical discharge of a child from a care provider program when the child has been approved for release/discharge from ORR custody or for transfer within the ORR provider network. Public reporting burden for this collection of information is estimated to average 0.17 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 (Homeland Security Act, 6 U.S.C. 279). 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.

R-2 | Version # Page 1 of 1

Revised MM/DD/20YY