DEPARTMENT OF HEALTH AND HUMAN SERVICES |
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OMB No. 0970-0034 |
Office of Refugee Resettlement |
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Exp. 11/30/2026 |
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Name of Youth |
Alien Registration No. |
HHS Tracking No. |
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First |
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Middle |
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ORR-3 REPORT FORM |
UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM |
PLACEMENT REPORT |
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State/URD Agency |
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Provider Agency |
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Agency Name: |
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Agency Name: |
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Address: |
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Address: |
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City: |
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City: |
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State: |
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Zip: |
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State: |
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Zip: |
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National Voluntary Agency |
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USCCB |
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LIRS |
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Not Applicable |
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Section I: Report Action |
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1. Initial Placement - Must be submitted within 30 days of placement |
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2. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change |
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Transfer to/from another URM Program |
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Date of Action (mm/dd/yyyy) |
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Transfer to |
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Transfer from |
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State Agency: |
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Provider Agency: |
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Change in identifying data (e.g., age, name, or A#) |
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Became a parent |
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Change in biological parent's location |
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Change in immigration data |
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Change in work authorization (i.e., Employment Authorization Document) |
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Change in placement type, placement cost, or youth's address |
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Establishment of or change in legal responsibility |
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Explain "Change of Status". |
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3. Termination: |
Date of Termination: |
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Reunified with parents |
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Not compliant with State/Program requirement(s) |
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Unified with relatives |
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Ran away |
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Adopted |
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Departed from U.S. (Removal or Voluntary Departure) |
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Became a U.S. Citizen |
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Immigration detention |
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Emancipated |
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Incarcerated |
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Concluded ORR-funded services/benefits |
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Deceased |
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Left program voluntarily |
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Other |
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Explain destination/current situation at case closure. |
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4. Re-entered for ORR-funded placement or services |
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Date of Re-entry (mm/dd/yyyy) |
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URM Placement |
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Services/Benefits only |
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Section II: Identifying/ Basic Data |
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1. Sex: |
2. Date of Birth |
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3. Date of Eligibility |
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4. Date of Initial Placement |
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5a. Country of Origin: |
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5b. Ethnic Group: |
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6a. Language of Origin: |
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6b. Other Language(s): |
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7. Eligibility Type: |
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Refugee |
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Asylee |
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C/H Entrant |
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U-Status Recipient |
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Ukrainian Humanitarian Parolee |
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Special Immigrant Juvenile (SIJ) |
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Afghan Humanitarian Parolee |
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Trafficking Victim |
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Other: |
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8. Caseworker/Provider Assessment on Personal Functioning of the Youth (complete at initial placement only): |
Assess the youth's functioning in the following areas at an age-appropriate level on a scale of 1 through 5, as indicated below. Provide an explanation if necessary. |
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Poor |
Below Average |
Average |
Above Average |
Excellent |
Explain |
English Language Skill |
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Education (other than English) |
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Health Condition |
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Mental Health |
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9. URM's Children in Care: |
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First Name, Middle Name, Last Name |
Date of Birth |
Citizenship / Immigration Status |
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1st child |
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2nd child |
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3rd child |
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10. Mother of URM: |
Last: |
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a. Living: |
b. Mother's address when minor arrived in U.S.: |
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Yes |
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No |
c. Current Address: |
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Unknown |
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Same as b. above |
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11. Father of URM: |
Last: |
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a. Living: |
b. Father's address when minor arrived in U.S.: |
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Yes |
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No |
c. Current Address: |
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Unknown |
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Section III: Immigration |
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1. Immigration |
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Refugee |
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Victim of Trafficking-No immigration status (OTIP letter only) |
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Asylee |
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U-Status Recipient |
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SIJ (I-360 approval) |
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T-Status Recipient |
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Afghan Humanitarian Parolee |
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Lawful Permanent Resident |
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Cuban/Haitian Entrant-No immigration status |
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Other: |
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Ukrainian Humanitarian Parolee |
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2. Youth is receiving immigration assistance. |
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* Change in immigration status may render a child no longer eligible for URM. Consult ORR immediately with questions. |
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Yes |
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No |
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3. Youth has work authorization/Employment Authorization Document. |
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Yes |
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No |
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Section IV: Placement |
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1. Placement Type: |
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2. Placement Cost: |
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(daily rate) |
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Foster Family Home |
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Therapeutic Foster Home |
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Group Home |
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Supervised Independent Living |
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Residential Treatment |
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Long-term hospitalization (more than 2 weeks) |
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Absent from program but legal responsibility retained |
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Living independently but receiving ORR-funded services/benefits |
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Other: |
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3. Youth's Residence: |
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4. Provider Agency for Placement: |
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Name: |
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Same as URM Provider |
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Relation of caregiver: |
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Placement via Subcontract |
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Address: |
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City: |
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State: |
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Zip: |
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Section V: Legal Responsibility |
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1. Legal responsibility has been petitioned. |
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Yes, it was petitioned within 30 days of enrollment. |
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Date: |
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Yes, it was petitioned past 30 days of enrollment. |
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Date: |
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No, it hasn't been petitioned. |
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2. Legal responsibility has been established in accordance with applicable State law. |
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Yes |
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Date: |
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No |
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2.a. In lieu of legal responsibility, youth has signed a Voluntary Placement Agreement. |
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Yes |
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Date: |
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No |
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3. Court name with jurisdiction: |
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4. Agency name to whom legal responsibility assigned: |
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Same as URM Provider |
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5. Legal responsibility has ended. |
Date Ended |
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Yes |
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No |
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Section VI: Report Submission Authority |
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1. Provider Agency |
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1. Provider Name |
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Address |
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City |
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State |
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Zip Code |
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User Name: |
Title: |
Agency Approval Date: |
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(mm/dd/yyyy) |
Phone: |
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Email: |
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Secondary contact: |
Title: |
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Phone: |
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Email: |
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2. State/URD Agency |
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Agency Name |
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Address |
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City |
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State |
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Zip Code |
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User Name: |
Title: |
Agency Approval Date: |
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(mm/dd/yyyy) |
Phone: |
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Email: |
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3. ORR |
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In immediate response to priorities of the current administration, this form has been updated with the following changes prior to approval by the Office of Management and Budget (OMB), as required by the Paperwork Reduction Act (PRA) of 1995 (44. USC. 3501 et seq.). The PRA requires that agencies obtain OMB approval before requesting information from the public, and OMB review and approval for most changes to an approved information. ACF is working to process these changes through OMB to come into compliance with the PRA but has implemented changes to the OMB-approved form to ensure compliance with the following Executive Orders: Executive Order(s) 14168 and/or 14151, 14173, 14224. Other than these changes, this form is approved under OMB #: 0970-0034. |