Form 1 Notice of Placement in Secure or Staff Secure

OMB Control No: 0970-XXXX
Expiration date: XX/XX/XXXX
ADMINISTRATION FOR CHILDREN AND FAMILIES
330 C Street, S.W. - Room 5123
Washington, D.C. 20201

U.S. Department of Health and Human Services

Office of Refugee Resettlement
Division of Children's Services
NOTICE OF PLACEMENT IN SECURE OR STAFF SECURE FACILITY
Minor's Name

Alien #:

Date of Birth

Country of Birth

Facility Name

Facility Type

This is to provide you NOTICE of the reasons for your placement in a secure or staff-secure facility. Your are in the care
and custody of the Office of Refugee Resettlement/Division of Children's Services (ORR/DCS). ORR/DCS will not place
a minor in a secure or staff-secure facility if there are less restrictive placement options available and appropriate.
However, under certain conditions listed below, ORR/DCS may place minors in a secure or staff-secure facility.
1. You are considered to be a flight risk.
2. You have committed or threatened to commit a violent or malicious act toward yourself or other(s).
3. You have been convicted of a crime as an adult.
4. You have been adjudicated as a delinquent.
5. You have engaged in serious, unacceptable disruptive behavior while in a licensed program.
6. You are chargeable with a crime or delinquent offense.
7. You are in criminal or delinquency proceedings.
8. For your own safety.
9. There is an emergency influx of minors into the United States and there are no alternative placement options at
this time. ORR will place you in a shelter care facility as expeditiously as possible.
If you have any questions or concerns regarding this placement, please discuss them with the facility case management
staff and/or your attorney of record. Any minor who disagrees with the ORR/DCS decision may correspond directly with
the ORR/ DCS Division Director. Additionally, the minor may seek judicial review in any United States District Court with
jurisdiction and venue over the matter to challange the placement decision.

__________________________________________
ORR Director Signature

_________________________
Date

__________________________________________
Facility Staff/Witness: Name/Signature/Position

_________________________
Date

__________________________________________

_________________________

CC: Minor
ORR/DCS Facility File
ORR/DCS Field Coordinator
ORR/DCS

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) Public reporting burden for this collection of information is estimated to average .10/ hour per response,
including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.