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["DEPARTMENT OF HEALTH AND HUMAN SERVICES",{"$nulls":15},"Form Approved"]
["Office of Refugee Resettlement",{"$nulls":15},"OMB No. 0970-0034"]
[]
["Name of Youth:",{"$nulls":7},"Alien No. ",{"$nulls":4}," HHS Tracking No."]
["Family",null,null,"Middle",null,"Given"]
[]
[]
["UNACCOMPANIED REFUGEE MINOR"]
["PLACEMENT REPORT"]
["FORM ORR-3"]
[]
["State Agency"]
["Agency Name"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone",{"$nulls":5},"Email"]
[]
["Section I. Report Action"]
["o","Initial placement - Must be submitted within 30 days",{"$nulls":7},"o","Re-entered ORR-funded services"]
[null,"o","UAC transfer",{"$nulls":7},"o","Foster care"]
["o","Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change",{"$nulls":8},"o","Independent Living"]
[null,"o","Establishing/changing legal responsibility"]
[null,"o","Placement change/change in address"]
[null,"o","Change in placement cost"]
[null,"o","Change in immigration status"]
[null,"o","Change in identifying data,e.g., name, age redetermination, received A#"]
[null,"o","Change in parents' location"]
[null,"o","Emancipated from foster care but receiving ORR-funded IL/education services"]
[null,"o","Became a parent"]
["o","Termination of ORR-funded services/Final Report:"]
[null,"o","Reunification with parent"]
[null,"o","Unification with:"]
[null,null,"o","Relative granted legal responsibility"]
[null,null,"o","Non-relative with legal responsibility"]
[null,"o","Adoption"]
[null,"o","Emancipation"]
[null,"o","Voluntary termination"]
[null,"o","Citizenship"]
[null,"o","Ran away"]
[null,"o","Loss of eligibility"]
[null,"o","Immigration detention"]
[null,"o","Incarcerated"]
[null,"o","Deceased"]
[null,"o","Other"]
["Explain destination/current situation at case closure."]
{"$rows_empty":9}
["Section II: Identifying Data"]
["1. Sex:",null,null,null,"2. Date of Birth",null,null,null,"3. Date of Eligibility"]
[null,"o","Female"]
[null,"o","Male"]
[{"$nulls":4},"4. Date of Initial Placement",null,null,null,"5. Estimated Date of Emancipation:"]
[]
["6a. Country of origin:",{"$nulls":7},"7a. Language of origin:"]
["6b. Ethnic group:",{"$nulls":7},"7b. Other language(s):"]
[]
["8. Eligibility Type:",{"$nulls":7},"9. Placement Type:"]
["o","Refugee",{"$nulls":6},"o","Overseas"]
["o","Asylee"]
["o","Entrant"]
["o","Trafficking Victim"]
["o","Special Immigrant Juvenile (SIJ)"]
["o","Other"]
[]
[]
["10. National Voluntary Agency",{"$nulls":4},"11. Parent of child",null,null,"Name(s)",null,null,"DOB",null,"Citizen/Immigration status"]
[{"$nulls":5},"o","1 child"]
[{"$nulls":5},"o","2 children"]
["Agency name",{"$nulls":4},"o","3 children"]
[]
["12. Mother's Name:"]
["Family",{"$nulls":4},"Middle",null,null,"Given"]
[]
["a. Living:",null,null,"b. Mother's address when minor arrived in U.S.:"]
["o","Yes"]
["o","No"]
["o","Unknown",null,"c. Current Address:"]
[]
["13. Father's Name:"]
["Family",{"$nulls":4},"Middle",null,null,"Given"]
[]
["a. Living:",null,null,"b. Father's address when minor arrived in U.S.:"]
["o","Yes"]
["o","No"]
["o","Unknown",null,"c. Current Address:"]
[]
[]
["Section III: Immigration Status Data"]
["Current Immigration Status/Situation",{"$nulls":6},"New Immigration Status/Situation"]
["o","Refugee",{"$nulls":5},"o","Lawful Permanent Resident"]
["o","Asylee",{"$nulls":5},"o","Asylee"]
["o","SIJ (I-360 approval)",{"$nulls":5},"o","T-Visa "]
["o","SIJS(I-485 approval)",{"$nulls":5},"o","U-Visa"]
["o","Amerasian",{"$nulls":5},"o","Ordered Removed"]
["o","Victim of Trafficking-No immigration status",{"$nulls":5},"o","Relief under Convention Against Torture"]
["o","Victim of Trafficking with T-Visa ",{"$nulls":5},"o","U.S. Citizen"]
["o","Victim of Trafficking with U-Visa",{"$nulls":5},"o","SIJS (I-485 approval)"]
["o","Cuban/Haitian Entrant-No immigration status",{"$nulls":5},"o","Parole"]
["o","Lawful Permanent Resident",{"$nulls":5},"o","Revocation of trafficking eligibility letter "]
["o","Parole",{"$nulls":5},"o","Other"]
["o","Other"]
[{"$nulls":7},"Change in immigration status may render a child no longer eligible for URM, particularly for Cuban/Haitian Entrants. Consult ORR.  U.S. citizens are no longer eligible for URM."]
[]
[]
[]
[]
["Section IV: Foster Care Placement Data"]
["1. Placement Type:",{"$nulls":5},"2. Placement Date:"]
["o","Relative"]
["o","Foster Care",{"$nulls":4},"3. Placement Cost:"]
["o","Therapeutic Foster Care",{"$nulls":4},"$",null,null,"(average daily rate)"]
["o","Group Home"]
["o","Semi-Independent Living"]
["o","Independent Living"]
["o","Residential Treatment"]
["o","Inpatient psychiatric hospital"]
["o","Other"]
["4. Foster Parents/Youth's Relative:",{"$nulls":6},"Relation"]
["Name:",{"$nulls":6},"Phone Number:"]
["Address"]
[]
["5. Provider Agency for Placement:"]
["Agency name",{"$nulls":6},"Phone Number:"]
["Address"]
[]
["6. Medical Coverage:"]
["o","Medicaid",null,"o","RMA","o","Other","If Other coverage provide name:"]
[]
[]
[]
["Section V: Legal Responsibility Data"]
["1. Court with jurisdiction:",{"$nulls":7},"Date petition filed:",null,null,"Date legal responsibility established:"]
["Name"]
["Address"]
[]
["2. Agency to whom legal responsibility assigned:"]
["Name"]
["Address"]
[]
["3. Has legal responsibility ended?",{"$nulls":7},"Date ended:"]
["o","Yes"]
["o","No"]
[]
["4. Voluntary Placement Agreement:",{"$nulls":7},"Date signed:"]
["o","Yes"]
["o","No"]
[]
[]
["Section VI: Independent Living Data"]
["1. Youth residence:"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone"]
[]
["2. Service Type:",{"$nulls":13},"Select funding source"]
[{"$nulls":14},"ORR","State/ Chafee","Private"]
["o","a.","Educational benefits (Ed)",{"$nulls":11},"o","o","o"]
["o","b.","Independent living (IL)",{"$nulls":11},"o","o","o"]
["3. For all ORR-funded services, list provider:"]
[null,null,"Agency Name:",{"$nulls":7},"Contact Information:"]
["a. Ed"]
["b. IL"]
[]
[]
[]
["Section VII: Form Submission Authority"]
["1. Unaccompanied Refugee Minor (URM) Provider Agency:"]
["Agency Name"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone",{"$nulls":5},"Email"]
["Signature of Person Preparing Form:",{"$nulls":7},"Date of signature:"]
[]
["Name"]
["Title"]
[]
["2. State Agency:"]
["Agency Name"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone",{"$nulls":5},"Email"]
["Signature of State Official Submitting Form:",{"$nulls":7},"Date of signature:"]
[]
["Name"]
["Title"]