Form P-11 Transfer Request and Tracking Form

OMB 0970-#### [Valid through MM/DD/2020]

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OFFICE OF REFUGEE RESETTLEMENT
Division of Children's Services
TRANSFER REQUEST AND TRACKING FORM
Minor's Profile
Alien Number

FINS Number

Last Name

First Name

AKA

Date of Placement in Current Facility

Height

Weight

DOB

Age

COB

Date of Initial Placement

Eye Color

Identifying Marks

Current Care Provider Facility
Current Program

Program Type

Address

City

Case Worker

State

Zip

Has the minor's attorney
been contacted?**

Care Provider Transfer Recommendation
Type of Facility Requested

Phone

Proposed Facility

Requestor

Request Date

Attorney of Record

Phone

ORR Transfer Decision
Name of ORR Decision Maker

Designated Care Provider Facility

Type of Care Provider Facility

New Care Provider Facility
New Program

Program Type
Secure

Address

City

State

Zip

Phone

Transfer Packet (for each minor)
Please follow checklist in the Transfer Procedures when completing
minor's transfer packet, check box to indicate the packet is completed
List of Minor's Belongings (be sure to include medication)

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 track the physical transfer of the UAC and their belongings. 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 UACPolicy@acf.hhs.gov.

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OFFICE OF REFUGEE RESETTLEMENT
Division of Children's Services
TRANSFER REQUEST AND TRACKING FORM

Departure/Arrival Information
Departure

Date

Time

Transportating
Staff

Name

Title

By signing below, I affirm that:
1) I have read the minor’s Case Summary and Individual Service Plan (ISP) and am aware of all documented special needs.
2) The list of the minor’s personal belongings is complete and accurate.
Signature ___________________________________________________________

Arrival

Date

Time

Receiving
Staff

Name

Date _____________________

Title

By signing below, I affirm that:
1) I have read the minor’s Case File Summary and Individual Service Plan (ISP) and am aware of all documented special needs.
2) The list of the minor’s personal belongings is complete and accurate.
Signature ___________________________________________________________

Date _____________________

Distribution of this form is restricted to ORR staff, grantees and contractors (including voluntary agencies, Child Advocates, and legal
service providers); UAC attorneys of record; the U.S. Department of Homeland Security; and the Executive Office for Immigration
Review. This form may not be distributed to any other party without the written authorization of ORR/DCS.