Form A-15 Form A-15 ORR Waiver Request

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: Choose an item.

POC Title:

WAIVER REQUEST #1
Requested Timeframe of Waiver:
☐Initial Request ☐ Renewal Request
Date of Initial Request _______
Date of Renewal(s)
_______; _______; ______
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
Requested Timeframe of Waiver:
☐ Initial Request ☐ Renewal Request
Date of Initial Request _______
Date of Renewal(s)
_______; _______; ______
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
Requested Timeframe of Waiver:
☐ Initial Request ☐ Renewal Request
Date of Initial Request _______
Date of Renewal(s)
_______; _______; ______
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:
☐ Approved

☐ Denied

WAIVER REQUEST #2
☐ Approved with conditions:

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

☐ Approved

☐Denied

WAIVER REQUEST #3
☐Approved with conditions:

PLAN OF SUPERVISION/TRAINING
☐ Select if a plan of supervision or training is attached to this form