Waiver Request Form__06252021

ORR WAIVER REQUEST FORM VERSION 1.0 (LAST UPDATED: JUNE 25, 2021)

GRANTEE/CONTRACTOR SECTION – TO BE COMPLETED BY THE REQUESTOR
Name of Facility/Provider:			Primary Point of Contact (POC) Name:
Address of Facility/Provider:			POC Phone No and Email:
Type of Facility/Provider:			POC Title:
WAIVER REQUEST #1
☐Initial Request ☐ Renewal Request Date of Initial Request _______ Date of Renewal(s) _______; _______; ______			Requested Timeframe of Waiver:
Specific waiver being requested:
Why is the waiver needed (Specific provision unable to meet and why):
What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?
WAIVER REQUEST #2
☐ Initial Request ☐ Renewal Request Date of Initial Request _______ Date of Renewal(s) _______; _______; ______			Requested Timeframe of Waiver:
Specific waiver being requested:
Why is the waiver needed (Specific provision unable to meet and why):
What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?
WAIVER REQUEST #3
☐ Initial Request ☐ Renewal Request Date of Initial Request _______ Date of Renewal(s) _______; _______; ______			Requested Timeframe of Waiver:
Specific waiver being requested:
Why is the waiver needed (Specific provision unable to meet and why):
What other provisions or mitigations can be implemented to maintain quality or reduce risk, including related state licensing requirements that will be adhered to?
OFFICE OF REFUGEE RESETTLEMENT (ORR) SECTION – TO BE COMPLETED BY APPROVER
WAIVER REQUEST #1
☐ Approved	☐ Denied	☐ Approved with conditions:
WAIVER REQUEST #2
☐ Approved	☐ Denied	☐ Approved with conditions:
WAIVER REQUEST #3
☐ Approved	☐Denied	☐Approved with conditions:
PLAN OF SUPERVISION/TRAINING
☐ Select if a plan of supervision or training is attached to this form