R-4 Release Request - Current UC Portal Version

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

Administration for Children & Families

Office of Refugee Resettlement

Release Request

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]

Release Request Details

Release Type [based on user selecting “Sponsor” or “Program,” only applicable fields will appear]

Sponsor/Program [text to auto-populate based on Release Recommendation Section]

1/2A/2B/3/4 [text auto-populates from Sponsor Assessment (Form S-5)]

Case Category

[text auto-populates from Sponsor Assessment (Form S-5)]

Relationship

[auto-populates based on user]

Case Manager Name:

[auto-populates based on user]

Case Coordinator Name:

[auto-populates based on user]

Local Federal Field Staff Name:

Sponsor Information

[Section displays if Release Type is “Sponsor,” selected under Release Request Details Section]

Name of Sponsor: [Auto-populates from Sponsor Assessment (Form S-5)]

AKA: [Auto-populates from Sponsor Assessment (Form S-5)]

Date of Birth: [Auto-populates from Sponsor Assessment (Form S-5)]

Current Age: [Auto-populates from Sponsor Assessment (Form S-5)]

Country of Birth: [Auto-populates from Sponsor Assessment (Form S-5)]

OTIP Eligibility

[Section displays if Release Type is “Sponsor” or “Program,” selected under Release Request Details Section]

Yes/No

OTIP Referral

Date of OTIP Referral

Yes/No

Is the unaccompanied child a material witness?

Outcome of OTIP Referral

[Outcome of OTIP Referral Drop-down Options:]

Final Eligibility

Interim Eligibility

Pending Notification

Not Eligible

[Following fields only appear if “Final Eligibility” or “Interim Eligibility” is selected]

Date OTIP eligibility begins

Date OTIP interim eligibility expires

Program Information

[Section only Displays if Release Type is “Program,” under Release Request Details section]

Program Type

[Program Type Drop-down Options:]

URM

State-Licensed Juvenile Shelter

State-Licensed Group Home

State-Licensed Foster Home

Local Social Service Agency

Other

URM Program Requirement Eligibility [Displays if “URM” is selected]:

¨ I-360

¨ I-485

¨ OTIP Eligibility Letter

¨ T-Visa

¨ Asylum Approval Letter

¨ Stamped I-94

¨ I-862

¨ I-94

¨ Other

Date the URM Eligibility was Obtained [Displays if “URM” is selected]

Program Name

Program Address

Program Primary Contact

Primary Contact Phone

Primary Contact Email

Yes/No

Program Agreed to Conditions of Release

How/Why Program was identified?

Program License Type

Case Manager Recommendation

[auto-populated based on user]

Case Manager Name:

Home Study

Case Manager Home Study Recommendation:
[Section displays if Release Type is “Sponsor,” selected under Release Request Details Section]

[Case Manager Home Study Recommendation Drop-down Options:]

Do not recommend Home Study

Home Study – TVPRA

Home Study – Discretionary

Home Study – ORR Mandated

Explain your rationale for recommending or not recommending a Home Study. (Note: a discretionary home study recommendation must have an explanation and directions that explain what the home study should focus on)

Release Recommendation

Case Manager Release Recommendation Date:

[auto-populated based on current date]

Case Manager Release Recommendation:

[Case Manager Release Recommendation Drop-down Options:]

Approve with Level 1 Post-Release Services

Approve with Level 2 Post-Release Services

Approve with Level 3 Post-Release Services

Release to Program (URM, State, Local Social Service Agency, Other)

Deny Release

[The following fields will not be able to be completed unless “Do Not Recommend Home Study” is selected under Home Study Recommendation Section or until the Home Study has been completed and a completion date is populated under Home Study Recommendation section]

Describe case factors that contribute positively to your release recommendation:

Describe case factors that contribute negatively to your release recommendation:

List all documents used as evidence to support your recommendation to deny release (“evidentiary record”) [only display when Release Recommendation is “Deny Release”]

Release Cancellation

Case Manager Cancellation Reason:

Sponsor Withdrawal – Household member(s) refused to complete requirements (ORR waiver not granted)

Sponsor Withdrawal – Sponsor unwilling to reunify due to immigration enforcement concern

Sponsor Withdrawal – New sponsor came forward

Sponsor Withdrawal – Sponsor is leaving the U.S.

Sponsor Withdrawal –Sponsor is moving (within the U.S.)

Sponsor Withdrawal – Sponsor changed their mind

Sponsor Withdrawal – Sponsor unable or unwilling to meet child’s healthcare needs

Sponsor Withdrawal – Other

Unaccompanied Child Discharge – Child ran away

Unaccompanied Child Discharge – Individual determined to be an adult

Unaccompanied Child Discharge – Child removed or voluntarily departed

Unaccompanied Child Discharge – Child detained by local law enforcement

Unaccompanied Child Discharge – Child detained by US Marshals

Unaccompanied Child Discharge – Child discharged with Unaccompanied Child Parent

Administrative Closure – Sponsor arrested

Administrative Closure – Sponsor failed to pick up child

Administrative Closure – Sponsor deceased

Administrative Closure – Sponsor refused to travel to pick up child

Administrative Closure – Sponsor lacks interest in sponsoring child – did not formally withdraw

Administrative Closure – Child deceased

Administrative Closure – Opened in error

Describe circumstances of release cancellation:

Case Coordinator Recommendation

[auto-populated based on user]

Case Coordinator Name:

Home Study

Case Coordinator Home Study Recommendation:

[Case Manager Home Study Recommendation Drop-down Options:]

Do not recommend Home Study

Home Study – TVPRA

Home Study – Discretionary

Home Study – ORR Mandated

Explain your rationale for recommending or not recommending a Home Study. (Note: a discretionary home study recommendation must have an explanation and directions that explain what the home study should focus on):

Release Recommendation

Case Coordinator Release Recommendation Date:

[auto-populated based on current date]

Case Coordinator Release Recommendation:

[Case Coordinator Release Recommendation Drop-down Options:]

Approve with Level 1 Post-Release Services

Approve with Level 2 Post-Release Services

Approve with Level 3 Post-Release Services

Pending Information

Deny Release

Case Coordinator Pending Information [will display only if Release Recommendation is “Pending Information”]:

[Case Coordinator Pending Information Drop-down Options:]

Pending admissible or consulate verified birth certificate

Sponsor fraud or identity concern

Incomplete Initial Medical Exam

Child’s medical concern needs further evaluation

Case does not meet Box criteria

Failed sponsorship upon reunification

Incomplete assessment

Pending previous sponsorship documents

Other

Other [only displays if “Other” is selected]:

[The following fields will not be able to be completed unless “Do Not Recommend Home Study” is selected under Home Study Recommendation Section or until the Home Study has been completed and a completion date is populated under Home Study Recommendation section]

Describe case factors that contribute positively to your release recommendation:

Describe case factors that contribute negatively to your release recommendation:

List all documents used as evidence to support your recommendation to deny release [only display when “Release Recommendation” is “Deny Release”

Release Cancellation

Case Coordinator Cancellation Reason:

Sponsor Withdrawal – Household member(s) refused to complete requirements (ORR waiver not granted)

Sponsor Withdrawal – Sponsor unwilling to reunify due to immigration enforcement concern

Sponsor Withdrawal – New sponsor came forward

Sponsor Withdrawal – Sponsor is leaving the U.S.

Sponsor Withdrawal –Sponsor is moving (within the U.S.)

Sponsor Withdrawal – Sponsor changed their mind

Sponsor Withdrawal – Sponsor unable or unwilling to meet child’s healthcare needs

Sponsor Withdrawal – Other

Unaccompanied Child Discharge – Child ran away

Unaccompanied Child Discharge – Individual determined to be an adult

Unaccompanied Child Discharge – Child removed or voluntarily departed

Unaccompanied Child Discharge – Child detained by local law enforcement

Unaccompanied Child Discharge – Child detained by US Marshals

Unaccompanied Child Discharge – Child discharged with Unaccompanied Child Parent

Administrative Closure – Sponsor arrested

Administrative Closure – Sponsor failed to pick up child

Administrative Closure – Sponsor deceased

Administrative Closure – Sponsor refused to travel to pick up child

Administrative Closure – Sponsor lacks interest in sponsoring child – did not formally withdraw

Administrative Closure – Child deceased

Administrative Closure – Opened in error

Describe circumstances of release cancellation:

ORR Decision

ORR Decision:

[ORR Decision Drop-down Options:]

Home Study – TVPRA

Home Study – Discretionary

Home Study – ORR Mandated

Approve with Post-Release Services

Remand

HOLD

Deny Release

Cancel Release

ORR Home Study Status:

[Opens when Home Study Decision selection is made:]

[ORR Home Study Status Drop-down Options:]

Home Study complete – positive recommendation

Home Study complete – negative recommendation

Complete – approve pending completion of conditions

Cancelled

In progress

ORR Decision After Home Study:

[ORR Release Decision Drop-down Options:]

Approve with Post-Release Services

Remand

HOLD

Deny Release

Cancel Release

ORR Remand Reason [will display only if Release Decision is “Remand”]:

[ORR Remand Reason Drop-down Options:]

Incomplete/Missing Documents – Sponsor Assessment

Incomplete/Missing Documents – Release Request

Incorrect UC or UC Info

Incorrect Sponsor or Sponsor Info

UC In-Transfer/Transferred

Original Issues Not Corrected

Other

ORR HOLD Reason [will display only if Release Decision is “HOLD”]

[ORR HOLD Drop-down Options:]

Notification of Denial Cat 1

Notification of Denial Cat 2A

Notification of Denial Cat 2B

Other

ORR Cancellation Reason:

Sponsor Withdrawal – Household member(s) refused to complete requirements (ORR waiver not granted)

Sponsor Withdrawal – Sponsor unwilling to reunify due to immigration enforcement concern

Sponsor Withdrawal – New sponsor came forward

Sponsor Withdrawal – Sponsor is leaving the U.S.

Sponsor Withdrawal –Sponsor is moving (within the U.S.)

Sponsor Withdrawal – Sponsor changed their mind

Sponsor Withdrawal – Sponsor unable or unwilling to meet child’s healthcare needs

Sponsor Withdrawal – Other

Unaccompanied Child Discharge – Child ran away

Unaccompanied Child Discharge – Individual determined to be an adult

Unaccompanied Child Discharge – Child removed or voluntarily departed

Unaccompanied Child Discharge – Child detained by local law enforcement

Unaccompanied Child Discharge – Child detained by US Marshals

Unaccompanied Child Discharge – Child discharged with Unaccompanied Child Parent

Administrative Closure – Sponsor arrested

Administrative Closure – Sponsor failed to pick up child

Administrative Closure – Sponsor deceased

Administrative Closure – Sponsor refused to travel to pick up child

Administrative Closure – Sponsor lacks interest in sponsoring child – did not formally withdraw

Administrative Closure – Child deceased

Administrative Closure – Opened in error

Decision History

ORR Decisionmaker Name:	[auto-populated]	ORR Decision Date:	[auto-populated]
ORR Release Decision:	[auto-populated]	Remand Reason:	[auto-populated]

Home Study

Explain your rationale for recommending or not recommending a Home Study. (Note: a discretionary home study recommendation must have an explanation and directions that explain what the home study should focus on):

Please summarize the results of the home study including any recommendations made by the Home Study provider, if there are any concerns, and how they were mitigated:

Release Decision

[The following fields will not be able to be completed unless “Do Not Recommend Home Study” is selected under Home Study Recommendation Section or until the Home Study has been completed and a completion date is populated under Home Study Recommendation section]

Describe case factors that contribute positively to your release recommendation:

Describe case factors that contribute negatively to your release recommendation:

List all documents used as evidence to support your recommendation to deny release [only display when “Release Recommendation” is “Deny Release”

Release Cancellation

Describe circumstances of release cancellation:

Program Release Dates

Release Scheduled Date:
The Next Scheduled Court Appearance for this Juvenile is:
Date Sponsor was Notified that They Must Inform the Immigration Court Directly of any Further Change of Address:
Reason for Less Than 24 Hours’ Notice to ICE, if Applicable:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to process recommendations and decisions for release of an unaccompanied child from ORR custody. Public reporting burden for this collection of information is estimated to average 0.42 hours per response for care providers and 0.33 hours per response for case coordinators, 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-4 | Version # Page 1 of 11

Revised MM/DD/20YY