 ORR-3 Unaccompanied Minors Placement
The Refugee Unaccompanied Minor Placement Report, which replaces ICPC-100B (the Interstate Compact on the Placement of Children Initial Placement Form), is an adaptation of that placement report.
The report is to be used for both refugee and entrant unaccompanied minors, as well as minor victims of a severe form of trafficking.
When Form is to be Filed
The Refugee Unaccompanied Minor Placement Report is to be used for the following reporting situations:
1) Initial Placement;
2) Change of Status (e.g., change of placement, change of legal responsibility, reunification with adult relatives, or reclassification*); and
3) Termination from the program (e.g., emancipation or parental reunification).
*Refer to 45 CFR 400.111 Definition.
Instructions for Filling Out Form
The following instructions address each section for the report. Check the box in the center of page one to indicate whether the report is: Initial Placement, Change of Status, or Final; and check the box for the Action Taken where necessary. Provide the child's alien number where indicated on page one and in the upper right corner of page two. Also, provide local provider case number on top of page one.
Note the distribution:
To: Self-explanatory
From: The signature and title of either the State Child Welfare Agency representative or provider agency representative is required. Also, provide the address of the agency.
Always complete Nos. 1, 4 and 9 of SECTION I-A. Complete other SECTIONS as appropriate.
SECTION I -- IDENTIFYING DATA
I-A
1. Name of Child: Self-explanatory
2. Birthdate: Include month, day, and year from I-94.
3. Sex: Self-explanatory
4. Alien Number: Self-explanatory; copy from I-94 form, or use the HHS tracking number for trafficking minors.
5. Social Security Number: Self-explanatory
6. Date Child Entered the U.S.: Enter the month, day, and year the minor arrived in the United States, from I-94 form, or the ORR eligibility letter for trafficking minors, or from the Immigration Judge’s Order, if granted asylum.
7. Estimated Date for Emancipation: Enter the estimated month and year the minor is expected to emancipate from the program.
8. Country of Origin: Enter the name of the minor's country of citizenship.
9. Refugee Status or Entrant Status: Indicate with a check mark the appropriate status.
I-B
10. Mother's Name: Provide the name (Family, Middle and Given), and if living, the last known address of the mother at the time the minor arrived in the U.S. Provide current address of mother, if different from above address. Indicate "Yes" or "No" in the blank as to whether or not the mother of the minor is living. Otherwise, enter "Uncertain."
11. Father's Name: Provide the name (Family, Middle and Given), and if living, the last known address of the father at the time the minor arrived in the U.S. Provide current address of father, if different from above address. Indicate "Yes" or "No" in the blank as to whether or not the father of the minor is living. Otherwise, enter "Uncertain."
12. National Voluntary Agency: The voluntary agency which sponsored the child or assisted in the placement of the child.
SECTION II -- PLACEMENT DATA
1. Type of Placement: Check the appropriate box for the type of placement for the minor.
2. Date: Indicate the actual date of the placement.
3. Foster Parents/Ethnic Group: Check “Yes” or “No” in the box to indicate whether the foster parents are of the same ethnic group as the minor.
4. Relative Placement: If placed with a relative, state the relationship of the relative to the minor. Also, provide the name, address, and phone number, including the area code, of the relative.
SECTION II -- PLACEMENT DATA (Continued)
5. Foster Parent/Agency with Whom the Child Placed: (a) Indicate the name, address, and phone number, including area code, of the foster parent/s. (b) Indicate the name, address, and phone number, including area code, of the provider agency supervising the care of the minor.
6. Supervising State Agency: Provide the name, address, and phone number including area code, of the supervising State agency.
SECTION III -- LEGAL RESPONSIBILITY DATA
1. Provide the name and address of the court having jurisdiction over the child.
2. Provide the date that the court established legal responsibility for the child.
3. Provide the name and address of the person and/or agency to whom legal responsibility was assigned.
SECTION IV -- PROGRAM TERMINATION*
1. Provide the reason for program termination. Also provide the date of termination.
2. Provide court determination upon program termination. Also provide the date of this court action.
3. Provide information on the destination of the child upon program termination, including address.
*Refer to 45 CFR 400.113
SECTION V -- This section requires the signature of the person preparing the report including name and title as well as phone number including the area code. Provide the date of the signature.
DISTRIBUTION OF REPORT:
Appropriate State Agency representative should send the original and copies of such reports to:
1) Office of Refugee Resettlement, Department of Health and Human Services;
2) ORR Regional Office, Department of Health and Human Services;
3) State Agency;
(4) National Voluntary Agency which was the sending agency listed on the ICPC-100A 9 preliminary Interstate Compact Form used for seeking approval for bringing child into the State);
(5) Originator (Local Public or Private Agency).
"THE PAPERWORK REDUCTION ACT OF 1995"
Public reporting burden for this collection of information is estimated to average 2 hours per response, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.
An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number.