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["DEPARTMENT OF HEALTH AND HUMAN SERVICES",{"$nulls":14},"Form Approved"]
["Office of Refugee Resettlement",{"$nulls":14},"OMB No. 0970-0034"]
[]
["Name of Youth:",{"$nulls":9},"Alien No. ",null,null," HHS Tracking No."]
["Family",null,null,null,"Middle",null,null,"Given"]
[]
[]
[" UNACCOMPANIED REFUGEE MINOR"]
["OUTCOMES REPORT"]
["FORM ORR-4"]
[]
["State Agency"]
["Agency Name"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone",{"$nulls":5},"Email:"]
[]
["Check the box below to indicate the type of report supported by the Form ORR-4:"]
["o","Standard annual progress report"]
["o","Report for youth age 21 and above in receipt of ORR-funded services consistent with State title IV-b or IV-E plan"]
["o","Follow-up annual outcomes report for youth age 17 to 21 who are no longer receiving services"]
["o","Report comprising only sections I, V, and VI for youth age 17 and above within 30 days of initial placement and in conjunction with Form ORR-3 initial placement report."]
[]
[]
["Section I.  Identifying Data"]
["1. Date of Birth",{"$nulls":6},"2. National Voluntary Agency"]
[]
[]
["3. URM Provider:"]
["Agency Name"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone",{"$nulls":5},"Email"]
[]
[]
["Section II. Personal Functioning of the Youth"]
["1. Education Information"]
[null,"a. Indicate the youth's current school grade level:"]
[null,"b. Check the appropriate box to indicate current school level and any additional curricula as appropriate:"]
[null,"o","Elementary",{"$nulls":4},"Provide additional curricular information:"]
[null,null,"o","Regular school program"]
[null,null,"o","Specialized school program"]
[null,"o","Secondary"]
[null,null,"o","College bound"]
[null,null,"o","Vocational"]
[null,null,"o","Business"]
[null,"o","Postsecondary",null,null,"Type of Degree Program:",{"$nulls":4},"Estimated Completion Date:"]
[null,"o","Not in school"]
[null,"c. Has the youth required and received any educational remedial services during the reporting period?"]
[null,null,"o","Yes",null,"o","No","If yes, please specify."]
[]
[]
[null,"d. For all youth age 16 and younger, indicate if the youth has obtained any educational or vocational skills, certificates or diplomas (including GED) since the last reporting period. For youth age 17 and above, complete Section V. Independent Living Outcomes."]
[{"$nulls":7},"If yes, please specify."]
[null,null,"o","Yes",null,"o","No"]
[]
[]
[]
[]
[]
["2. Caseworker/Provider Assessment"]
["Assess the youth's functioning in the following four areas where Adequate means functioning at an age-appropriate level. Provide an explanation if selecting Not Adequate. "]
[{"$nulls":5},"Adequate",null,"Not Adequate",null,"Explanation"]
["English Language Skill",{"$nulls":4},"o",null,"o"]
[]
["Education (other than English)",{"$nulls":4},"o",null,"o"]
[]
["Social Adjustment",{"$nulls":4},"o",null,"o"]
[]
["Health Condition",{"$nulls":4},"o",null,"o"]
[]
[]
[]
["Section III. Family Reunifcation Activity"]
["Family reunification data for either parental or relative reunification. Describe current efforts to reunify the youth with his or her parents. Include any, even partial, family reunification information such as names, addresses, phone numbers, etc. "]
[{"$nulls":8},"Month","Day","Year"]
["1. Date of the most recent permanency plan review:"]
[]
["2. Describe efforts to locate and assess parents and potential relative caregivers in the U.S. for possible reunification, including name, address and phone number. If relatives have been located and reunification has been ruled out at this point in time for a youth under the age of 18, explain why. "]
[]
[]
[]
[]
[]
[]
["3. Describe efforts to locate or trace parents or other potential relative caregivers who are overseas, including name, address and phone number, and the status of any efforts to support the relative to obtain immigration status in the U.S."]
[]
[]
[]
[]
[]
[]
["4. Describe efforts to connect URMs with siblings or other relatives too young to serve as caregivers, including name, relation and phone number."]
[]
[]
[]
[]
[]
["Section IV: Independent Living Services"]
["1. Youth residence:"]
["Street Address"]
["City",{"$nulls":5},"State",null,"Zip Code"]
["Phone"]
[]
[{"$nulls":10},"Select funding source"]
["2. Service Type:",{"$nulls":9},"ORR","State/ Chafee","Private"]
["a.","Foster care status - services"]
["o","i.","Adjudicated delinquent"]
[null,"ii.","Educational level",{"$nulls":4},"(up to grade 12, post-secondary, or college)"]
["o","iii.","Special education"]
["o","iv.","Independent living needs assessment",{"$nulls":7},"o","o","o"]
["o","v.","Academic support",{"$nulls":7},"o","o","o"]
["o","vi.","Post-secondary educational support",{"$nulls":7},"o","o","o"]
["o","vii.","Career preparation",{"$nulls":7},"o","o","o"]
["o","viii.","Employment programs/vocational training",{"$nulls":7},"o","o","o"]
["o","ix.","Budget and financial management",{"$nulls":7},"o","o","o"]
["o","x.","Housing education /home management training",{"$nulls":7},"o","o","o"]
["o","xi.","Health education & risk prevention",{"$nulls":7},"o","o","o"]
["o","xii.","Family support & healthy marriage education",{"$nulls":7},"o","o","o"]
["o","xiii.","Mentoring",{"$nulls":7},"o","o","o"]
["o","xiv.","Supervised independent living",{"$nulls":7},"o","o","o"]
["o","xv.","Room & board financial assistance",{"$nulls":7},"o","o","o"]
["o","xvi.","Education financial assistance",{"$nulls":7},"o","o","o"]
["o","xvii.","Other financial assistance",null,null,null,"Type:",null,null,null,"o","o","o"]
[]
["b. For all ORR-funded services, list provider:"]
["(#)",null,"Agency Name:",{"$nulls":5},"Contact Information:"]
[]
[]
[]
[]
["Section V: Independent Living Outcomes"]
["Data Element",{"$nulls":7},"Question to youth and response options"]
["1.","Outcomes reporting status:"]
["o","a. Youth participated"]
["o","b. Youth declined"]
["o","c. Incapacitated"]
["o","d. Incarcerated"]
["o","e. Runaway/missing"]
["o","f. Unable to locate/invite"]
["o","g. Death"]
["2. ","Date of outcome data collection:",{"$nulls":4},"Month","Day","Year"]
[]
[]
[{"$nulls":7},"Queries",null,null,null,"Responses"]
["3. ","Foster care status - outcomes:",{"$nulls":9},"Yes","No","Declined","NA","Don't Know"]
[null,"Youth remains in foster care",{"$nulls":9},"o","o"]
["4. ","Current full-time employment",{"$nulls":5},"Are you currently employed full-time?",null,null,null,"o","o","o"]
["5.","Current part-time employment",{"$nulls":5},"Are you currently employed part-time?",null,null,null,"o","o","o"]
["6.","Employment-related skills",{"$nulls":5},"In the past year, did you complete an apprenticeship, internship or other on the job training, either paid or unpaid?",null,null,null,"o","o","o"]
["7.","Social Security",{"$nulls":5},"Are you currently receiving SSI, Disability or other dependents' payments?",null,null,null,"o","o","o"]
["8.","Educational aid",{"$nulls":5},"Are you currently using a scholarship, grant, stipend, student loan, voucher or other education financial aid to cover educational expenses?",null,null,null,"o","o","o"]
["9.","Public financial assistance",{"$nulls":5},"Are you currently receiving ongoing welfare [State TANF] payments to support your basic needs?",null,null,null,"o","o","o","o"]
["10.","Public food assistance",{"$nulls":5},"Are you currently receiving public food assistance [SNAP or community program]?",null,null,null,"o","o","o","o"]
["11.","Public housing assistance",{"$nulls":5},"Are you currently receiving any sort of public housing assistance?",null,null,null,"o","o","o","o"]
["12.","Other financial support",{"$nulls":5},"Are you currently receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment?",null,null,null,"o","o","o"]
["13.","Highest educational certification received",{"$nulls":5},"What is the highest educational degree or certification that you have received?"]
[null,"a. GED",{"$nulls":9},"o","o","o"]
[null,"b. high school diploma",{"$nulls":9},"o","o","o"]
[null,"c. vocational certificate",{"$nulls":9},"o","o","o"]
[null,"d. vocational license",{"$nulls":9},"o","o","o"]
[null,"e. associate's degree",{"$nulls":9},"o","o","o"]
[null,"f. bachelor's degree",{"$nulls":9},"o","o","o"]
[null,"g. higher degree",{"$nulls":9},"o","o","o"]
[null,"h. none of the above",{"$nulls":9},"o","o","o"]
["14.","Current enrollment and attendance",{"$nulls":5},"Are you currently enrolled in and attending high school, GED classes, post-high school vocational training or college?",null,null,null,"o","o","o"]
["15. Connection to adult",{"$nulls":6},"Is there currently at least one adult in your life, other than your caseworker to whom you can go for advice or emotional support?",null,null,null,"o","o","o"]
["16.","Homelessness",{"$nulls":5},"Have you ever been homeless at any time?",null,null,null,"o","o","o"]
["17.","Substance abuse referral",{"$nulls":5},"Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling?",null,null,null,"o","o","o"]
["18. ","Incarceration",{"$nulls":5},"Have you ever been confined in a jail or other correctional facility or juvenile detention in connection with allegedly committing a crime?",null,null,null,"o","o","o"]
[]
[{"$nulls":7},"Queries",null,null,null,"Responses"]
[{"$nulls":11},"Yes","No","Declined","NA","Don't Know"]
["19. ","Children",{"$nulls":5},"Have you ever given birth or fathered any children that were born?",null,null,null,"o","o","o"]
["20.","Marriage at child's birth",{"$nulls":5},"If yes, were you married to the child's other parent at the time?",null,null,null,"o","o","o","o"]
["21.","Medicaid",{"$nulls":5},"Are you currently on Medicaid [or use the name of the State's medical assistance program under title XIX]?",null,null,null,"o","o","o"]
["22.","Other health insurance coverage",{"$nulls":5},"Do you currently have heatlh insurance other than Medicaid?",null,null,null,"o","o","o","o","o"]
["23.","Health insurance type: Medical",{"$nulls":5},"Does your health insurance include coverage for medical services?",null,null,null,"o","o","o","o","o"]
["24.","Health insurance type: Mental health",{"$nulls":5},"Does your health insurance include coverage for mental health services?",null,null,null,"o","o","o","o","o"]
["25.","Health  insurance type: Prescription drugs",{"$nulls":5},"Does your health insurance include coverage for prescription drugs?",null,null,null,"o","o","o","o","o"]
["26.","Health insurance type: Other",{"$nulls":5},"Does your health insurance include coverage for other services, e.g., dental or vision",null,null,null,"o","o","o","o","o"]
[{"$nulls":7},"Other type of coverage:"]
[]
[]
["Section VI: Form Submission Authority"]
["1. 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:"]