ORR-1, CMA Program Estimates

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Overview

INSTRUCTIONS
ORR-1 PREP FORM
ADMIN BUDGET AT-A-GLANCE
ADMIN BUDGET WORKSHEET
LINE 1(a) RCA BENEFICIARY COSTS
LINE 2(a) RMA BENEFICIARY COSTS
LINE 2(c) MEDICAL SCREENING
LINE 3(a) SERVICES FOR URM

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Sheet 1: INSTRUCTIONS

										OMB N0. 0970-0030 Expires XX/XX/XXXX
OFFICE OF REFUGEE RESETTLEMENT
ORR-1 Cash and Medical Assistance Budget Estimate and Justification
General Overview
In order to receive quarterly Cash and Medical Assistance Grants (CMA) grants for cash assistance, medical assistance, services to unaccompanied refugee minors, and related administrative costs, a State or Replacement Designee (RD) must submit to ORR an estimate for reimbursable costs for the federal fiscal year (FFY), identified by type of expense and justification in support of the estimate. You must submit this estimate and justification no later than 45 days prior to the beginning of the FFY, in accordance with guidelines prescribed by the ORR Director (45 CFR §400.11(b)(1)). The ORR-1 CMA Budget Estimate and Justification has two parts: 1) the ORR-1 form to report CMA estimates by program component and administrative costs for the FY; and 2) this document, the ORR-1 Instructions and Budget Workbook, to help you develop and justify your budget estimate for that ORR-1 form. The workbook includes the following: • INSTRUCTIONS: Instructions on completing the ORR-1 Instructions and Budget Workbook and the ORR-1 form. • ORR-1 PREP FORM: This form updates upon completion of the ORR-1 budget workbook; it is designed for you to use to populate the ORR-1 form in the Grant Solutions On-Line Data Collection. • ADMIN BUDGET AT-A-GLANCE: Summary table of administrative costs that auto-populates with the data entered in ADMIN BUDGET WORKSHEET. • ADMIN BUDGET WORKSHEET: Worksheet to develop and justify the administrative budget. The columns titled with LINE 1(b), LINE 2(b), LINE 2(d), LINE 3(b), and LINE 4 auto populate the corresponding lines on the ORR-1 prep form. • LINE 1(a) RCA BENEFICIARY COSTS: Worksheet to develop and justify the RCA beneficiary costs. • LINE 2(a) RMA BENEFICIARY COSTS: Worksheet to develop and justify the RMA beneficiary costs. • LINE 2(c) MEDICAL SCREENING: Worksheet to develop and justify medical screening costs. • LINE 3(a) SERVICES FOR URM: Worksheet to develop and justify services for URM costs. Upon completion of the ORR-1 Instructions and Budget Workbook, the ORR-1 PREP FORM will auto populate, and you should use this information to populate the ORR-1 form in the Grant Solutions On-Line Data Collection. Due Date: The ORR-1 CMA Budget Estimate and Justification is due annually on August 15. Submission: The ORR-1 CMA Budget Estimate and Justification must be submitted via the OLDC section in GrantSolutions. Recipients must enter CMA estimates directly in the ORR-1 form in the GrantSolutions On-Line Data Collection and upload the ORR-1 Instructions and Budget Workbook as an attachment.
Instructions
These INSTRUCTIONS follow the format of the ORR-1 form and refer to related worksheets in the ORR-1 Instructions and Budget Workbook. Each worksheet follows the instructions included on this tab, with additional detail dispersed throughout relevant sections of the worksheet to walk you through completion of each sections. The worksheets are locked to eliminate errors in calculations. The ORR-1 PREP FORM will auto-populate based on information entered into each section of the workbook. You should use this information to populate the ORR-1 form in the Grant Solutions On-Line Data Collection. You must upload the ORR-1 budget workbook as an attachment to the ORR-1 form.
1. Refugee Cash Assistance (RCA)
	(a) RCA Beneficiary Costs
	Report estimated cash assistance costs on line 1(a) of the ORR-1 form.
	Step 1: Calculate the Estimated Average Monthly Unit Cost and enter the number in the appropriate field within the workbook tab titled Line 1(a) RCA BENEFICIARY COSTS. • The monthly RCA unit costs should be consistent with applicable RCA/TANF rates as indicated in your state plan.
	Step 2: Calculate the Estimated Average Monthly Beneficiaries and enter the number in the appropriate field within the workbook tab titled Line 1(a) RCA BENEFICIARY COSTS. • Round the average monthly beneficiaries rounded up to the nearest whole number. Do not use decimals.
	Step 3: Justify the monthly unit cost estimate (e.g., based on previous monthly expenditure) and the number of monthly beneficiaries in the appropriate field within the workbook tab titled Line 1(a) RCA BENEFICIARY COSTS
	Step 4: Data from the workbook tab titled Line 1(a) RCA BENEFICIARY COSTS will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(b) RCA Administration
	Report direct and indirect cost estimated for the administration of the RCA program on line 1(b) of the ORR-1 form: • Include staff supervision and oversight, local travel for RCA intakes, interpretation and translation services for RCA beneficiaries, and other administrative direct and indirect costs estimated for performing tasks related to RCA intakes, eligibility determinations, and distribution of benefits. • If the State Refugee Coordinator's office conducts RCA eligibility determinations, include the cost of dedicated staff performing that task.
	Step 1: Calculate RCA Administration costs. • In the ORR-1 budget workbook tab labeled ADMIN BUDGET WORKSHEET, enter estimates costs for staff supervision and oversight, local travel for RCA intakes, interpretation and translation services for RCA beneficiaries, and other administrative direct and indirect costs estimated for performing tasks related to RCA intakes, eligibility determinations, and distribution of benefits. • For each cost category, provide justification and/or cost factors for deriving the estimated amount based on: staff FTE, function, and benefits; travel costs justified by number of staff and travel purpose (e.g., consultation, training, quarterly meetings, technical assistance, monitoring); and overhead.
	Step 2: Data from the workbook tab titled ADMIN BUDGET WORKSHEET will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(c) Subtotal
	The sum of RCA Beneficiary Costs and RCA Administration will automatically calculate the subtotal of the estimated RCA expenditures and auto populate in the workbook tab titled ORR-1 PREP FORM
2. Refugee Medical Assistance (RMA)
	(a) RMA Beneficiary Costs
	On line 2(a) of the ORR-1, report the Estimated Total Fiscal Year Expenditures for RMA beneficiary costs (Column D), including but not limited to: • Costs of medical services for RMA beneficiaries. • Costs of monthly premiums/capitation fees, as well as additional claims/encounters. • Interpretation and transportation costs for medical services provided to RMA beneficiaries in parallel with the Medicaid program in the state. • Medical screening related services billed through the RMA health coverage program as a covered benefit. Do NOT include medical screening costs billed separately from the RMA health coverage program.
	Step 1: Calculate the Estimated Total Fiscal Year Expenditures for RMA beneficiary costs and enter the number in the appropriate field within the workbook tab titled Line 2(a) RMA BENEFICIARY COSTS.
	Step 2: Calculate the Estimated Annual Beneficiaries for RMA beneficiary costs and enter the number in the appropriate field within the workbook tab titled Line 2(a) RMA BENEFICIARY COSTS
	Step 3: Provide an RMA Justification Statement in the appropriate field within the workbook tab titled Line 2(a) RMA BENEFICIARY COSTS
	Step 4: Data from the workbook tab titled Line 2(a) RMA BENEFICIARY COSTS will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(b) RMA Administration
	Report direct and indirect costs estimated for the administration of the RMA program by a state's Medicaid agency, local public assistance offices, and any other administering agencies on line 2(b) of the ORR-1 form: • Include personnel and other administrative direct and indirect costs estimated for performing tasks related to RMA intakes, RMA eligibility determinations, and provision of RMA benefits. • If a recipient combines RMA and RCA eligibility administrative costs during the public assistance intake, the recipient may report the cost on the RCA line but should indicate RMA is combined in the justification statement. •If the SRC office conducts RMA eligibility determinations, include the cost of dedicated staff conducting RMA eligibility determinations on line 2(b). Do NOT include SRC and SRC staff oversight of the RMA program; this should be included on ORR-1 line 4, Administration - Program Coordination and Planning.
	Step 1: Calculate RMA Administration costs. • In the ORR-1 budget workbook tab labeled ADMIN BUDGET WORKSHEET, enter the personnel, travel, and other administrative costs for RMA Administration. • For each cost category, provide justification and/or cost factors for deriving the estimated amount based on: staff FTE, function, and benefits; travel costs justified by number of staff and travel purpose (e.g., consultation, training, quarterly meetings, technical assistance, monitoring); and overhead.
	Step 2: Data from the workbook tab titled ADMIN BUDGET WORKSHEET will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(c) Medical Screening
	On line 2(c) of the ORR-1 form, report allowable costs of local health departments, screening clinics, and other health and non-health agencies under agreement with the SRC and/or the Refugee Health Coordinator (RHC) involved in the provision of medical screenings, including but not limited to: • Personnel and administrative costs of subrecipients necessary for the provision of medical screening, such as coordination to ensure timeliness and accessibility, data entry, and other administrative tasks. • Direct costs of medical services (e.g., cost of a test or cost of bundled services). • Interpretation and transportation for medical screening beneficiaries (allowable if activity is not already provided by the Department of State (DOS)/Bureau of Populations, Refugees, and Migration (PRM) Reception & Placement program (R&P). • Other costs necessary for the provision of medical screening. Do NOT include on line 2(c) the medical screening costs billed through the RMA health coverage program or the RHC and RHC staff costs, even if the RHC is a subrecipient of the SRC.
	Step 1: Calculate the Estimated Total Fiscal Year Expenditure for Medical Screening and enter the number in the appropriate field within the workbook tab titled Line 2(c) MEDICAL SCREENING.
	Step 2: Calculate the Estimated Annual Beneficiaries for Medical Screening and enter the number in the appropriate field within the workbook tab titled Line 2(c) MEDICAL SCREENING.
	Step 3: Provide Medical Screening Subrecipients in the appropriate fields within the workbook tab titled Line 2(c) MEDICAL SCREENING, consistent with the instructions provided therein.
	Step 4: Provide the Medical Screening Fee Schedule in the appropriate fields within the workbook tab titled Line 2(c) MEDICAL SCREENING, consistent with the instructions therein.
	Step 5: Provide a Medical Screening Justification Statement in the appropriate field within the workbook tab titled Line 2(c) MEDICAL SCREENING.
	Step 6: Data from the workbook tab titled Line 2(c) MEDICAL SCREENING will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(d) Medical Screening Administration and Health Coordination
	On line 2(d) of the ORR-1 form, report allowable costs of the RHC and RHC staff involved in the administration of the medical screening program and overall coordination of health-related activities, including but not limited to: • Personnel and administrative costs of the RHC and RHC staff, including but not limited to management, planning, coordination, policy and program development, oversight, monitoring, consultation, training, technical assistance, travel, data collection, and reporting. • RHC office indirect and allocated costs, in accordance with approved state Indirect Cost Rate Agreements and Cost Allocation Plans. • Include the costs of the RHC and health staff dedicated to the administration of the medical screening program and overall coordination of health-related activities on line 2(d) even if they reside in the same office as the SRC. Do not include these costs on ORR-1 line 4, Administration - Program Coordination and Planning.
	Step 1: Calculate Medical Screening Administration and Health Coordination costs. • In the ORR-1 budget workbook tab labeled ADMIN BUDGET WORKSHEET, enter the personnel, travel, and other administrative costs for Medical Screening Administration and Health Coordination. • For each cost category, provide justification and/or cost factors for deriving the estimated amount based on: staff FTE, function, and benefits; travel costs justified by number of staff and travel purpose (e.g., consultation, training, quarterly meetings, technical assistance, monitoring); and overhead.
	Step 2: Data from the workbook tab titled ADMIN BUDGET WORKSHEET will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(e) Subtotal
	The RMA Beneficiary Costs, RMA Administration, Medical Screening, and Medical Screening Administration and Health Coordination will automatically sum to determine the subtotal of the estimated RMA expenditures and will be auto populated in the workbook tab titled ORR-1 PREP FORM.
3. Unaccompanied Refugee Minors (URM)
	(a) Services for URMs
	On line 3(a) of the ORR-1 form, report all allowable costs of counties, URM provider agencies, and other service providers under agreement with the state to provide children and youth enrolled in the URM program approved benefits and services available to other foster youth in the state, per federal regulations and ORR policy, including but not limited to: • Core services including case management, family reunification, health care, mental health services, social adjustment, English language learning, education and vocational training, career planning and employment, preparation for independent living and social integration, preservation of ethnic and religious heritage, coordination of immigration assistance, and transition to adulthood services and benefits. • Expenditures incurred in establishing legal responsibility • Services identified in the State's plans under titles IV-B and IV-E of the Social Security Act, and services permissible under title XX of the Social Security Act • Administrative costs incurred by subrecipients in the provision of child welfare services to URMs • Indirect and allocated costs, in accordance with approved state Indirect Cost Rate Agreements and Cost Allocation Plans
	Step 1: Calculate the Estimated Total Fiscal Year Expenditures and enter the number in the appropriate field within the workbook tab labeled LINE 3(a) SERVICES FOR URM.
	Step 2: Calculate the Estimated Average Monthly Beneficiaries and enter the number in the appropriate field within the workbook tab labeled LINE 3(a) SERVICES FOR URM. When making this calculation, recipients should obtain refugee minor (M4s) arrival estimates from the DOS/PRM and use historical national level projection of ORR referred eligible URM populations to formulate estimate. Recipients may use a client loading chart to calculate the average number of monthly URM beneficiaries and include beneficiaries anticipated to roll over from the previous year.
	Step 3: Estimated Average Monthly Unit Cost for URM services will auto populate in the appropriate field within the workbook tab labeled LINE 3(a) SERVICES FOR URM.
	Step 4: Provide Subrecipient(s) and Budget Categories in the appropriate fields within the workbook tab titled Line 3(a) SERVICES FOR URM, consistent with the instructions provided therein, including items #1-9
	Step 5: Provide the Budget Justification and Narrative in the appropriate fields within the workbook tab titled Line 3(a) SERVICES FOR URM, consistent with the instructions provided therein.
	Step 6: Provide an Identification of Attachments in the appropriate field within the workbook tab titled Line 3(a) SERVICES FOR URM, consistent with the instructions provided therein. Upon completion of Estimated Total Fiscal Year Expenditures, Estimated Average Monthly Beneficiaries, Subrecipient(s) and Budget Categories, and the Budget Justification and Narrative, any associated documentation should also be uploaded into OLDC as attachments. Please identify the attachments the recipient is uploading.
	Step 7: Data from the workbook tab titled Line 3(a) SERVICES FOR URM will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(b) URM Program Administration
	On line 3(b) of the ORR-1 form, report all allowable costs of the SRC, SRC office and/or other state agency (e.g., child welfare or medical assistance agency) related to the administration of the URM program, including but not limited to: • Personnel, management, planning, coordination, policy and program development, oversight, monitoring, consultation, training, technical assistance, travel, data collection, and reporting. • SRC office and/or other state agency indirect and allocated costs, in accordance with approved state Indirect Cost Rate Agreements and Cost Allocation Plans.
	Step 1: Calculate URM Program Administration costs. • In the ORR-1 budget workbook tab labeled ADMIN BUDGET WORKSHEET, enter the personnel, travel, and other administrative costs for URM Program Administration. • For each cost category, provide justification and/or cost factors for deriving the estimated amount based on: staff FTE, function, and benefits; travel costs justified by number of staff and travel purpose (e.g., consultation, training, quarterly meetings, technical assistance, monitoring); and overhead.
	Step 2: Data from the workbook tab titled ADMIN BUDGET WORKSHEET will auto populate in the workbook tab titled ORR-1 PREP FORM.
	(c) Subtotal
	The sum of Services for URM and URM Program Administration will automatically calculate the subtotal of the estimated URM expenditures and auto populate in the workbook tab titled ORR-1 PREP FORM
4. Administration - Program Coordination and Planning
	On line 4 of the ORR-1 form, report: • Administrative costs estimated for the overall management of the state refugee program, including personnel and travel costs for the SRC or RD lead and staff, coordination, planning, policy and program development, oversight, monitoring, consultation, data collection, reporting, and travel. Examples include: development of state plans, program and service coordination, development of program instructions, program monitoring to meet ORR requirements, training and technical assistance provided by state core staff to local government and private sector service providers, interagency coordination where applicable, and conferences and related travel as allowable. All personnel costs should be in accordance with the amount of time devoted to activities specifically allocable to the administration of CMA for eligible populations. • For contractual costs, include administrative costs. In the narrative sections accompanying each cost category in ADMIN BUDGET WORKSHEET, specify which portion of each cost is administrative. • Indirect and allocated costs, in accordance with approved state Indirect Cost Rate Agreements and Cost Allocation Plans. Do not include administrative costs related to the administration of medical screening, or overall coordination of health-related activities on Line 4, even if the RHC reports directly to the SRC. These costs should be allocated to line 2(d) on the ADMIN BUDGET WORKSHEET.
	Step 1: Calculate program coordination and planning administration costs. • In the ORR-1 Budget Instructions & Workbook tab labeled ADMIN BUDGET WORKSHEET, enter the personnel, travel, and other administrative costs for Program Coordination and Planning. • For each cost category, provide justification and/or cost factors for deriving the estimated amount based on: staff FTE, function, and benefits; travel costs justified by number of staff and travel purpose (e.g., consultation, training, quarterly meetings, technical assistance, monitoring); and overhead.
	Step 2: Data from the workbook tab titled ADMIN BUDGET WORKSHEET will auto populate in the workbook tab titled ORR-1 PREP FORM.
5. Total Administration
	The sum of the data entered in the workbook tab titled ADMIN BUDGET WORKSHEET will automatically calculate the estimated Total Administration expenditures and auto populate in the workbook tab titled ORR-1 PREP FORM, as well as the workbook tab titled ADMIN BUDGET AT-A-GLANCE.
6. Total Estimate
	The total estimated Fiscal Year expenditures are automatically calculated. Upon completion of the ORR-1 Instructions and Budget Workbook, the ORR-1 PREP FORM will auto populate. You should use this information to populate the ORR-1 form in the Grant Solutions On-Line Data Collection. When using the GrantSolutions/OLDC, the ORR-1 still requires you to enter manually the Total Estimate based upon entries provided. If the OLDC detects an error in the math upon final submission, you receive an error message and can check calculations and entries to correct the estimate.
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to serve as the application for grants under the Cash and Medical Assistance (CMA) program. Public reporting burden for this collection of information is estimated to average 0.6 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 required by ORR program regulations at 45 CFR 400.11(b). 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. The OMB # is 0970-0030 and the expiration date is XX/XX/XXXX. If you have any comments on this collection of information, please contact draprograms@acf.hhs.gov.

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Sheet 2: ORR-1 PREP FORM

Department of Health and Human Services				OMB N0. 0970-0030
Administration for Children and Families				Approval Expires XX-XX-XXXX
OFFICE OF REFUGEE RESETTLEMENT
ORR-1 FORM CASH AND MEDICAL ASSISTANCE PROGRAM ESTIMATES
Recipient:			Federal Fiscal Year:
Cash and Medical Assistance		Estimated Average	Estimated Average	Estimated Total Fiscal
Program Components		Monthly Unit Cost	Monthly Beneficiaries	Year Expenditures1
(Column A)		(Column B)	(Column C)	(Column D)
1. Refugee Cash Assistance (RCA)	(a) RCA Beneficiary Costs	$-	0.00	$-
	(b) RCA Administration			$-
	(c) Subtotal			$-
2. Refugee Medical Assistance (RMA)	(a) RMA Beneficiary Costs			$-
	(b) RMA Administration			$-
	(c) Medical Screening2			$-
	(d) Medical Screening Administration and Health Coordination2			$-
	(e) Subtotal			$-
3. Unaccompanied Refugee Minors (URM)	(a) Services for URMs	#DIV/0!	0.00	$-
	(b) URM Program Administration			$-
	(c) Subtotal			$-
4. Administration - Program Coordination and Planning3				$-
5. Total Administration4				$-
6. Total Estimate5				$-
Signature of Approving Official		Name and Title of Approving Official		Date Report Submitted:
Telephone Number:		E-mail Address:
1Annualized monthly costs for rows 1(a) and 3(a), in column B are multiplied by the figure in column C and then multiplied by 12.
2Include only medical screening and medical screening administration and health coordination costs paid through RMA.
3In accordance with 45 CFR § 400.13(c).
4Total Administration equals sum of lines 1(b), 2(b), 2(d), 3(b), and 4 of column D.
5Total Estimate equals sum of lines 1(c), 2(e), 3(c), and 4 of column D.

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Sheet 3: ADMIN BUDGET AT-A-GLANCE

Recipient:
Federal Fiscal Year:
ADMINISTRATIVE BUDGET AT-A-GLANCE
This worksheet provides an easy-to-view snapshot of the total administrative costs by category in Columns E-J in TAB-4 ADMIN BUDGET WORKSHEET. Column G is your TOTAL ADMINISTRATIVE BUDGET. Office of Grants Management (OGM) will award funds on a quarterly basis.
OBJECT CLASS CATEGORIES	RCA Administration (Line 1b)	RMA Administration (Line 2b)	Medical Screening Administration and Health Coordination (Line 2d)	URM Program Administration (Line 3b)	Program Coordination & Planning (Line 4)	Total Administration (Line 5)
PERSONNEL	$-	$-	$-	$-	$-	$-
FRINGE	$-	$-	$-	$-	$-	$-
TRAVEL	$-	$-	$-	$-	$-	$-
EQUIPMENT	$-	$-	$-	$-	$-	$-
SUPPLIES	$-	$-	$-	$-	$-	$-
CONTRACTUAL	$-	$-	$-	$-	$-	$-
OTHER	$-	$-	$-	$-	$-	$-
INDIRECT/ALLOCATED COSTS	$-	$-	$-	$-	$-	$-
TOTAL	$-	$-	$-	$-	$-	$-

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Sheet 4: ADMIN BUDGET WORKSHEET

	ADMINISTRATIVE BUDGET WORKSHEET & JUSTIFICATION
	Recipient:
	Federal Fiscal Year:
	TABLE OF CONTENTS: Click on a section listed in the Table of Contents below to be linked to the section within the page.
	• Personnel
	• Fringe
	• Travel
	• Equipment
	• Supplies
	• Contractual
	• Other
	• Allocated & Indirect Costs
	• Additional Justification
	PERSONNEL: List all the personnel positions supported by the CMA grant and provide a brief position description. The title of the position is sufficient; the names of specific individuals is not necessary. Enter the staff member's salary attributable to each program, per TAB-1 INSTRUCTIONS. Enter the FTE applied to the CMA grant for each position. For example, if a staff member's salary is applied 100% to the CMA grant, enter 1.0. If a staff member's salary is applied 50% to the CMA grant, enter 0.5. If a staff member conducts work across multiple program areas, their FTE should be applied to Program Coordination & Planning (Line 4) and not split across multiple columns. FTE should include only those staff members working for the primary recipient (e.g., SRC and/or SRHC offices) and not staff members working for subrecipients (i.e., local resettlement agencies).
	POSITION	DESCRIPTION	FTE	ORR-1 Admin Line					TOTAL ADMIN (Line 5)
				RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-
	TOTAL PERSONNEL:			$-	$-	$-	$-	$-	$-
	TOTAL FTE:		0.00
	FRINGE: Fringe benefits include, but are not limited to, the costs of leave (vacation, family-related, sick or military), employee insurance, pensions, and unemployment benefit plans. Provide the lump sum fringe benefits in the appropriate ORR-1 Admin line (Columns E-I). The application across ORR-1 Admin lines should be consistent with the distribution of costs in the PERSONNEL section. Fringe costs do not need to be broken out by staff member.
				RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
	TOTAL FRINGE:			$-	$-	$-	$-	$-	$-
	GENERAL COMMENTS:
	TRAVEL: Travel costs are the expenses for transportation, lodging, subsistence, and related items incurred by employees who are in travel status on official business. Enter text to indicate the source of the calculations (e.g., state travel system, Airline websites, Travelocity, Kayak, etc.).
	GENERAL COMMENTS:
	LOCAL TRAVEL: Provide the requested information for all local travel as a lump sum in the section below. Under DESCRIPTION, provide the justification for travel including number of staff traveling locally, general areas of the state in which local travel will occur, and what costs will be incurred (e.g., mileage, per diem, rental cars, etc.).
	NAME OF EVENT	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
	Local Travel			$-	$-	$-	$-	$-	$-
	NON-LOCAL TRAVEL: Please provide the requested information for all non-local travel in the sections below. Under DESCRIPTION, provide the justification for travel including number of staff traveling non-locally, location of travel, and what costs will be incurred (i.e., mileage, per diem, rental cars, etc.). Each travel occurrence must be listed separately.
	NAME OF EVENT	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
	TOTAL TRAVEL (LOCAL & NON-LOCAL):			$-	$-	$-	$-	$-	$-
	EQUIPMENT: Equipment means tangible personal property (including information technology systems) having a useful life of more than one year and a per-unit acquisition cost which equals or exceeds $10,000.
	TYPE OF EQUIPMENT	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
	TOTAL EQUIPMENT:			$-	$-	$-	$-	$-	$-
	SUPPLIES: (Consumable Office Supplies) Supplies means all tangible personal property other than those included in Equipment.
	TYPE OF SUPPLIES	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
	TOTAL SUPPLIES:			$-	$-	$-	$-	$-	$-
	CONTRACTUAL: No contractual costs should be applied to lines 2(d) (Medical Screening Admin & Health Coordination) and 3(b) (URM Admin) in TAB-4 ADMIN BUDGET WORKSHEET. Such contractual costs should be included in TAB-6 MEDICAL SCREENING and TAB-7 SERVICES FOR URM. Under DESCRIPTION, briefly describe the scope of work and include a description of how costs are calculated, if applicable.
	CONTRACT	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
				$-	$-			$-	$-
	TOTAL CONTRACTUAL:			$-	$-			$-	$-
	OTHER: Costs not included in any of the above line items, including but not limited to: Rent & Facilities costs not covered by indirect or allocated costs; and Maintenance & Operation of Equipment not covered in contractual costs or supplies.
	TITLE	DESCRIPTION		RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
				$-	$-	$-	$-	$-	$-
	TOTAL OTHER:			$-	$-	$-	$-	$-	$-
	ALLOCATED & INDIRECT COSTS: Indirect costs means those costs incurred for a common or joint purpose benefitting more than one cost objective, and not readily assignable to the cost objectives specifically benefitted, without effort disproportionate to the results achieved. Allocated costs are central service costs that can be identified and assigned to benefitted activities on a reasonable and consistent basis in accordance with approved Cost Allocation Plans. All allocated or indirect costs should be applied to appropriate ORR-1 Admin line by department as applicable. For example, if the State Refugee Coordinator's department has an indirect cost rate agreement, it should be applied to Line 4 (Program Coordination & Planning); if the Refugee Health Coordinator's department has an indirect costs it should be applied to Line 2(d) (Medical Screening Administration and Health Coordination). Under GENERAL COMMENTS, explain whether the grant uses an indirect cost rate and/or cost allocation plan, how Allocated or Indirect Costs are calculated, and what those costs support. Provide a link to or submit a copy of the relevant approved Cost Allocation Plan or Indirect Cost Rate Agreement.
				RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
	TOTAL ALLOCATED & INDIRECT COSTS:			$-	$-	$-	$-	$-	$-
	GENERAL COMMENTS:
	ADDITIONAL JUSTIFICATION: Please include any additional justification of costs not captured in the fields above including, but not limited to: - explanation of any significant changes from the prior year; - clarification of any important information regarding estimates; and - any other important factor impacting recipient's administrative costs.
				RCA Admin (Line 1(b))	RMA Admin (Line 2(b))	Medical Screening Admin & Health Coordination (Line 2(d))	URM Admin (Line 3(b))	Program Coordination & Planning (Line 4)	TOTAL ADMIN (Line 5)
	TOTAL ADMINISTRATION:			$-	$-	$-	$-	$-	$-

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Sheet 5: LINE 1(a) RCA BENEFICIARY COSTS

	RCA BENEFICIARY COST JUSTIFICATION (ORR-1 Form Line 1(a))
						Estimated Average Monthly Unit Cost	Estimated Average Monthly Beneficiaries	Estimated Total Fiscal Year Expenditure
	TOTAL RCA BENEFICIARY COSTS (ORR-1 Line 1(a))					$-	0	$-
	When estimating the average monthly beneficiaries, you should: • Obtain refugee and SIV arrival estimates from the Department of State/PRM and local affiliates for all projected NEW arrival numbers and sponsored cases, and use historical data to formulate estimates for other populations expected to be served (e.g., asylees, entrants, trafficking victims) for the FY beginning 10/1. • Consider national level projections of ORR-eligible populations, if provided by ORR. • The average monthly beneficiaries should be rounded up to the nearest whole number. Do not use decimals.
	RCA JUSTIFICATION STATEMENT: For cost included in Line 1(a) of the ORR-1, Justify the monthly unit cost estimate (e.g., based on previous monthly expenditure) and the number of monthly beneficiaries. Specify the number of arrived/served clients by eligibility category used to formulate the estimate.

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Sheet 6: LINE 2(a) RMA BENEFICIARY COSTS

RMA BENEFICIARY COST JUSTIFICATION (ORR-1 Form Line 2(a))
						Estimated Total Fiscal Year Expenditure
TOTAL RMA BENEFICIARY COSTS (ORR-1 Line 2(a))						$-
Estimated Annual Beneficiaries Consider the following in calculating annual beneficiaries: • Obtain refugee and SIV arrival estimates from the Department of State/PRM and local affiliate for all projected NEW arrival numbers and sponsored cases, and use historical data to formulate estimates for other populations expected to be served (e.g., asylees, entrants, trafficking victims) for the FY beginning 10/1. • Consider national level projections of ORR-eligible populations if provided by ORR. • Factor in Medicaid expansion if the state has expanded Medicaid.						0
RMA JUSTIFICATION STATEMENT: For cost included in Line 2(a) of the ORR-1, provide a rationale for estimating the annual unit cost (e.g., based on previous expenditure) and annual beneficiaries. Please specify the number of arrived/served clients by eligibility category used to formulate the estimate.

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Sheet 7: LINE 2(c) MEDICAL SCREENING

	MEDICAL SCREENING COST JUSTIFICATION (ORR-1 Form Line 2(c))
				Estimated Total Fiscal Year Expenditure
		TOTAL MEDICAL SCREENING COSTS (ORR-1 Line 2(c))		$-
	ESTIMATED ANNUAL BENEFICIARIES Enter the number of estimated annual beneficiaries. Consider the following in calculating annual beneficiaries: • Obtain refugee and SIV arrival estimates from the Department of State/PRM and local voluntary resettlement agencies for all projected NEW arrival numbers and sponsored cases, and use historical data to formulate estimates for other populations expected to be served (asylees, entrants, trafficking victims) for the FY beginning 10/1. • Consider national level projections of ORR-eligible populations if provided by ORR. • Consider historical medical screening participation rate in the state.			ESTIMATED ANNUAL BENEFICIARIES
	MEDICAL SCREENING SUBRECIPIENTS:
	List each confirmed and pending subrecipient name and briefly describe their scope of work related to medical screening. Indicate if an agreement with a proposed subrecipient is pending. A subrecipient is any agency the grantee provides CMA funding to for the provision of medical screening, whether through grants, contracts, MOUs, interagency agreements, and/or other arrangements. If a state has a structure where subrecipients are too numerous to list (e.g., the recipient utilizes all county health departments), the recipient may describe similar subrecipients providing a similar scope of work, on one line (e.g., all county health departments in a specific area of the state provides comprehensive medical screenings); the categories (personnel, direct medical services, etc.,) should be estimated. Recipients may add additional lines as necessary. The total estimated subrecipient costs should total Line 2c Medical Screening on the ORR-1 Form. Under POPULATION/SERVICE AREA, provide information on the number or proportion of medical screening clients served, or of the areas of the state served. Under PERSONNEL, enter each subrecipient's total salaries and fringe benefits of personnel necessary for the provision of medical screening. Under FTE, enter the FTE applied to the Medical Screening program funded by the CMA grant for each position. Under ADMINISTRATIVE COST, enter each subrecipient's total administrative costs necessary for the provision of medical screening. Under DIRECT MEDICAL SERVICES, enter each subrecipient's total direct medical service costs, as applicable. The direct medical services costs should be based on the fee schedule noted below. Under INTERPRETATION & TRANSPORTATION, enter each subrecipient's total interpretation and transportation costs for medical screening recipients. Under OTHER, enter each subrecipient's total other costs necessary for the provision of medical screening; if selecting OTHER because recipients costs cannot be distributed among the given cost categories, please provide an explanation and description of services provided in the MEDICAL SCREENING JUSTIFICATION STATEMENT below.
	SUBRECIPIENT NAME	SCOPE OF WORK	POPULATION/SERVICE AREA	FTE	PERSONNEL	ADMINISTRATIVE COSTS	DIRECT MEDICAL SERVICES	INTERPRETATION & TRANSPORTATION	OTHER	TOTAL
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
				0.00	$-	$-	$-	$-	$-	$-
	TOTAL SUBRECIPIENT COSTS:			0.00	$-	$-	$-	$-	$-	$-
	MEDICAL SCREENING FEE SCHEDULE:
	List the medical screening service description and associated costs on each line. Grantees may attach fee schedules as applicable. - Include costs for direct medical services (e.g., vaccinations) and describe as necessary (e.g. ACIP vaccinations for adults). - Include flat rates for coordination/administration costs if negotiated per unit and describe as necessary. - If there are bundled rates, list the bundled services on one line and the associated rate. - If a grantee uses some other payment model describe the services and the associated costs. - If the fee schedule varies by screening clinic, grantees should specify the differences by clinic. - If there are exceptions to the standard fee schedule in a state, please explain why in the MEDICAL SCREENING JUSTIFICATION STATEMENT below.
										COST
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
										$-
	MEDICAL SCREENING JUSTIFICATION STATEMENT:
	Provide a justification statement for the estimated costs on Line 2c of the ORR-1 and LINE 2(c) MEDICAL SCREENING including, but not limited to: - explanation of how recipients determined the Estimated Total Fiscal Year Expenditures on line 2c Medical Screening on the ORR-1 Form; - justification for how the Medical Screening fee schedule was negotiated; - clarification of any important information regarding subrecipient estimates; - rational for annual medical screening beneficiaries; and - any other important factor impacting grantee's medical screening costs.

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Sheet 8: LINE 3(a) SERVICES FOR URM

	SERVICES FOR URM (ORR-1 Form Line 3(a))
	Part 1: ORR-1 3. Unaccompanied Refugee Minors (URM)
			Estimated Average Monthly Unit Cost (Column B)	Estimated Average Monthly Beneficiaries (Column C)	Estimated Total Fiscal Year Expenditures (Column D)
		a. Services for URMs	#DIV/0!	0	$-
	Part 2: Subrecipient(s) and Budget Categories
	1. SUBRECIPIENT(s)-- list all entities that work with a your agency for the purpose of URM services provision, including URM providers, contractors, public (or government) agencies, and other partners that are funded by the CMA grant to provide URM placement, services or benefits. 2. DESCRIPTION -- briefly describe their scope of work related to URM services 3. TOTAL FTE -- enter the full time equivalent of each subrecipient's URM allocation 4. PERSONNEL & FRINGE -- enter the total of salaries and fringe benefits 5. PLACEMENT -- enter the total placement cost of items such as foster care maintenance, semi-independent living placement, group homes, specialized or sub-contracted placements 6. BENEFITS & SERVICES -- enter the total cost for benefits and services provided to children and youth not already included in other columns 7. TRANSITION TO ADULTHOOD SERVICES/EDUCATION AND TRAINING VOUCHERS -- enter estimate for ORR-funded transition to adulthood benefits and services, including ETVs, comparable to those offered through the states’ Chafee program, in alignment with ORR policy 8. OPERATION & ADMIN -- enter the total cost for operation, supplies, human resources, and/or staff related costs not already included in #3 9. OTHER -- enter indirect and other costs not included in any of the other line items on this tab 7 10. TOTAL -- once you fill out #3 - #9, this total column will auto populate 11. TOTAL SUBRECIPIENT(s) COSTS -- will auto populate once you fill out #3 - # 9
	1. SUBRECIPIENT(s)	2. DESCRIPTION	3. TOTAL FTE	4. PERSONNEL & FRINGE	5. PLACEMENT	6. BENEFITS & SERVICES	7. TRANSITION TO ADULTHOOD SERVICES/EDUCATION AND TRAINING VOUCHERS	8. OPERATION & ADMIN	9. OTHER	10. TOTAL
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
			0.00	$-	$-	$-	$-	$-	$-	$-
	11. TOTAL SUBRECIPIENT(s) COSTS:		0.00	$-	$-	$-	$-	$-	$-	$-
	Part 3: Budget Justification and Narrative
	Provide budget justification and narrative for the following as attachments and budget summary in the space below. 1. Explain how you determined, using what method, the Estimated Average Monthly Beneficiaries (e.g., a loading chart) 2. Provide subrecipient budgets and budget narratives, or budget estimates 3. Explain the breakdowns and cost factors for each budget category (Part 2, Items #3 – 9) 4. Explain how placement costs have been estimated; include estimates for each placement type 5. Explain contracts for placement(s) and their budget estimate 6. Explain any other important factors impacting subrecipient costs and significant changes from the prior year 7. Provide a budget summary in the below space
	Budget Summary:
	Part 4: Identification of Attachments
	Upon completion of Part 1, 2, and 3, you must list and upload any associated documentation. Supplemental documentation should be uploaded into OLDC as attachments. Please identify the attachments the state has uploaded. 1. Justification for Average Monthly Beneficiaries (Part 1) 2. Loading charts (Part 1) 3. Justification on placement costs for diverse Placement Types (Part 2) 4. Contracts and their Budget Estimate (Part 2) 5. Justification narrative including details on the breakdowns on budget categories (Part 2 and 3)