Form 1 ORR-5 (New January 2021)

Refugee Data Submission System for Formula Funds Allocations (ORR–5)

4. ORR-5 Form_07.2022.xlsx

Refugee Data Submission for Formula Funds Allocations(ORR-5) –Revised (for use after January 2021)

OMB: 0970-0043

Document [xlsx]
Download: xlsx | pdf

Overview

ORR-5 Sections I&II
ORR-5 Section III


Sheet 1: ORR-5 Sections I&II







Refugee Data Submission System for Formula Funds Allocations and Service Analysis (ORR–5): Sections I & II







OMB #: 0970-0043














Expiration Date: XX/XX/XXXX
SECTION I: BASIC INFORMATION SECTION II: RSS FAMILY SELF-SUFFICIENCY PLAN (FSSP) INITIAL ASSESSMENT AND REFERRAL
1. Alien Number 2. Principal Applicant (PA) Alien Number 3. Relationship to PA 4. First Name 5. Middle Name 6. Last Name 7. DOB 8. Status or Category 9. Gender 10. Nationality 11. Zip Code 12. City 13. County 14. Eligibility Date 15. Migration Status 16. Date of Migration 17. Refugee Cash Assistance (RCA) Enrollment Date 18. RCA
Exit Date
19. Refugee Medical Assistance (RMA)
Enrollment Date
20. RMA
Exit Date
21. Medical Screening
Enrollment Date
22. Medical Screening
Exit Date
23. Refugee Support Services (RSS)
Enrollment Date
24. RSS
Exit Date
25. RSS FSSP
English Ability
26. RSS FSSP
Education Level
27. RSS FSSP
Initial Primary Goal (G1)
28. RSS FSSP
Initial Referral Relevant to G1












































































































































































































































































































































































PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client goals, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making, and data collected in section I will guide resource allocation. Public reporting burden for this collection of information is estimated to average 140 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 [Immigration and Nationality Act, section 412(a)(3)]. 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 draprograms@acf.hhs.gov.




















Sheet 2: ORR-5 Section III




Refugee Data Submission System for Formula Funds Allocations and Service Analysis (ORR–5): Section III OMB #: 0970-0043



Expiration Date: XX/XX/XXXX
SECTION III: RSS FSSP 12-MONTH FOLLOW-UP
29. Refugee Arrivals Data System (RADS) Case ID 30. RADS Individual ID 31. Alien Number 32. RSS FSSP
Initial Primary Goal Met?
33. RSS FSSP
Employment Status
34a. RSS FSSP
Total Number of Months Employed
Full-Time
34b. RSS FSSP
Total Number of Months Employed
Part-Time
34c. RSS FSSP
First Employment Date
34d. RSS FSSP
Best Hourly Wage
35. RSS FSSP
How Was 12-Month Follow-Up Information Collected?






























































































































































































PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client goals, services utilized, and the outcomes achieved by the population served. The data will be used to inform evidence-based policy making, and data collected in section I will guide resource allocation. Public reporting burden for this collection of information is estimated to average 140 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 [Immigration and Nationality Act, section 412(a)(3)]. 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 draprograms@acf.hhs.gov.




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