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["DEPARTMENT OF HEALTH AND HUMAN SERVICES",{"$nulls":15},"OMB No. 0970-XXXX"]
["Office of Refugee Resettlement ",{"$nulls":15},"Exp. XX/XX/XXXX"]
[]
["Name of Youth",{"$nulls":10},"Alien Registration No. ",null,null," HHS Tracking No."]
["Last",null,null,null,"First",null,null,null,"Middle"]
[]
[]
[]
["ORR-3 REPORT FORM"]
["UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM"]
["PLACEMENT REPORT"]
[]
["State Agency",{"$nulls":8},"URM Provider Agency"]
[]
["Agency Name:",{"$nulls":8},"Agency Name:"]
["Address:",{"$nulls":8},"Address:"]
["City:",{"$nulls":8},"City:"]
["State:",{"$nulls":4},"Zip:",null,null,null,"State:",{"$nulls":4},"Zip:"]
[]
["National Voluntary Agency",{"$nulls":9},"USCCB",null,"LIRS",null,"Not Applicable"]
[]
["Section I: Report Action"]
[]
[null,"1. Initial Placement - Must be submitted within 30 days of placement"]
[]
[null,"2. Change of Status - Action Taken (check all that apply) - Must be submitted within 60 days of the change"]
[]
[{"$nulls":12},"Date of Action (mm/dd/yyyy)"]
[null,null,"Establishing/changing legal responsibility"]
[null,null,"Transfer to/from another URM Program**"]
[null,null,"Change in placement type and address"]
[null,null,"Change in placement cost"]
[null,null,"Change in immigration/eligibility data"]
[null,null,"Change in biological parent's location"]
[null,null,"Absent from program but legal custody retained"]
[null,null,"Emancipated from placement services but receiving ORR-funded IL/education services"]
[null,null,"Became a parent"]
[null,null,"Change in identifying data,e.g., age redetermination, name, received A#,"]
[null,null,"or development of a safety plan."]
[null,"**","Please note which State Provider youth is transferring to/from in the explanation box below"]
[]
[" Explain \"Change of Status\" if necessary"]
[]
[]
[]
[]
[]
[]
[null,"3. Termination of ORR-funded services/Final Report:",{"$nulls":8},"Date of Termination:"]
[]
[null,null,"Reunified with Parents:  ",{"$nulls":7},"Dismissed from Program"]
[null,null,null,"within the US",{"$nulls":6},"Ran Away"]
[null,null,null,"Overseas",{"$nulls":6},"Departure from US:"]
[null,null,"Unification with ",{"$nulls":8},"Removal"]
[null,null,null,"Relative (Granted Legal Responsibility) ",{"$nulls":7},"Voluntary Departure "]
[null,null,null,"Non-relative (Granted Legal Responsibility)",{"$nulls":6},"Citizenship"]
[null,null,"Adoption",{"$nulls":7},"Loss of Eligibility"]
[null,null,"Emancipation",{"$nulls":7},"Immigration Detention"]
[null,null,null,"with state / Chafee-funded IL / Education services",{"$nulls":6},"Incarcerated"]
[null,null,"Conclusion of ORR-funded IL / Education services",{"$nulls":7},"Deceased"]
[null,null,"Voluntary Termination",{"$nulls":7},"Other"]
[]
["Explain destination/current situation at case closure."]
[]
[]
[]
[]
[]
[]
[null,"4. Re-entered ORR-funded placement and/or services",{"$nulls":10},"Date of Re-entry (mm/dd/yyyy)"]
[]
[null,null,"URM Placement",{"$nulls":4},"Independent Living Services"]
[]
[]
[]
["Section II: Identifying/ Basic Data"]
[]
["1. Sex:",null,null,null,"2. Date of Birth",null,null,null,"3. Date of Eligibility",null,null,null,"4. Date of Initial Placement"]
[null,"Female",null,"Male"]
[{"$nulls":4},"5a. Est. Emancipation from Placement",{"$nulls":4},"5b. Est. Date of Termination from ORR-funded IL / Edu. Services"]
[]
["6a. Country of Origin:",{"$nulls":8},"6b. Ethnic Group:"]
[]
["7a. Language of Origin:",{"$nulls":8},"7b. Other Language(s):"]
[]
[]
[]
["8. Eligibility Type:"]
[]
[null,"Refugee",null,null,null,"Asylee ",null,null,"Entrant ",null,null,null,"U Status Recipient"]
[]
[null,"Trafficking Victim",null,null,null,"Special Immigrant Juvenile (SIJ)",{"$nulls":6},"Other:"]
[]
[]
[]
["9. Has a safety plan been developed?  ",{"$nulls":5},"Yes",null,null,"No",null,null,"Not applicable"]
[]
[]
[]
["10. URM's Children in Care:"]
[{"$nulls":4},"First Name, Second Name, Last Name",{"$nulls":4},"DOB",null,null,null,"Citizenship / Immigration Status"]
[null,"1st child"]
[null,"2nd child"]
[null,"3rd child"]
[]
[]
[]
["11. Mother of URM:"]
["Last: ",{"$nulls":5},"First:",{"$nulls":5},"Middle:"]
[]
["a. Living:",null,null,"b. Mother's address when minor arrived in U.S.:"]
[null,"Yes"]
[null,"No",null,"c. Current Address:"]
[null,"Unknown",null,null,"Same as b. above"]
[]
["12. Father of URM:"]
["Last: ",{"$nulls":5},"First:",{"$nulls":5},"Middle:"]
[]
["a. Living:",null,null,"b. Father's address when minor arrived in U.S.:"]
[null,"Yes"]
[null,"No",null,"c. Current Address:"]
[null,"Unknown",null,null,"Same as b. above"]
[]
[]
["Section III: Immigration Data and Immigration Assistance"]
[]
["1. Immigration / Eligibility Data",{"$nulls":8},"U Status Recipient"]
[null,"Refugee",{"$nulls":7},"Cuban/Haitian Entrant-No immigration status"]
[null,"Asylee",{"$nulls":7},"Parole"]
[null,"SIJ (I-360 approval)",{"$nulls":7},"U.S. Citizen"]
[null,"Amerasian",{"$nulls":7},"Ordered Removed"]
[null,"Victim of Trafficking-No immigration status",{"$nulls":7},"Relief under Convention Against Torture"]
[null,"Victim of Trafficking with T-Visa ",{"$nulls":7},"Deferred Action"]
[null,"Victim of Trafficking with U-Visa",{"$nulls":7},"Revocation of Trafficking Eligibility Letter "]
[null,"Legal Permanent Resident",{"$nulls":8},"with Immigration Status"]
[{"$nulls":10},"without Immigration Status"]
["2.  Is youth receiving immigration assistance?",{"$nulls":8},"Other:"]
[null,"Yes",null,"No",null,"NA"]
[null,null,"Pro bono attorney",{"$nulls":5},"*","Change in immigration/eligibility data may render a child no longer eligible for URM, particularly for Cuban/Haitian Entrants. Consult ORR. "]
[null,null,"Pro bono accredited representative"]
[null,null,"Social or legal  service agency"]
[null,null,"Other: ",{"$nulls":5},"*","URMs who become U.S. citizens are no longer eligible for URM."]
[]
[]
[]
["Section IV: Placement Data"]
[]
["1. Placement Type:",{"$nulls":8},"2. Placement Cost: $ ",{"$nulls":4},"(average daily rate)"]
[null,"Relative Foster Care  "]
[null,"Foster Care"]
[null,"Therapeutic Foster Care"]
[null,"Group Home"]
[null,"Semi-Independent Living"]
[null,"Residential Treatment"]
[null,"Inpatient psychiatric hospital"]
[null,"No Placement (enter youth living independently in Sec. VI: IL Residence and Services)"]
[null,"Other"]
[]
[]
["3. Caregiver Residence",{"$nulls":8},"4. Provider Agency for Placement:"]
[{"$nulls":9},"       Same as placement agency"]
["Name:",{"$nulls":8},"Name:"]
["Relation of caregiver:"]
["Address:",{"$nulls":8},"Address:"]
["City:",{"$nulls":8},"City:"]
["State:",{"$nulls":4},"Zip:",null,null,null,"State:",{"$nulls":4},"Zip:"]
[]
[]
[]
["Section V: Legal Responsibility Data"]
[]
["1. Court with Jurisdiction:",{"$nulls":7},"Date Petition Filed:",null,null,"Date Legal Responsibility Est.:",null,null,null,"            Pending"]
["Name:"]
["Address:"]
["City:",{"$nulls":6},"State:",{"$nulls":4},"Zip Code:"]
[]
[]
[]
["2. Agency to Whom Legal Responsibility Assigned:"]
["Name:"]
["Address:"]
["City:",{"$nulls":6},"State:",{"$nulls":4},"Zip Code:"]
[]
[]
[]
["3. Has Legal Responsibility Ended?",{"$nulls":7},"Date Ended"]
[null,"Yes",null,null,null,"No"]
[]
["4. Voluntary Placement Agreement:",{"$nulls":7},"Date Signed"]
[null,"Yes",null,null,null,"No"]
[]
[]
[]
["Section VI: Independent Living Residence and Services"]
["1. Youth residence:"]
[]
["Address:"]
["City:",{"$nulls":6},"State:",{"$nulls":4},"Zip Code:"]
[]
[]
["2. Independent Living - URM placement has ended",{"$nulls":7},"Yes",null," Stipend Amount (monthly rate): $"]
[{"$nulls":9}," Stipend Amount (avg. daily rate): $"]
["3. Independent Living Services:",{"$nulls":12},"Select Funding Source"]
[{"$nulls":13},"ORR","State/ Chafee","Private","Other"]
[]
[null,"a. Educational benefits (Ed)"]
[null,"b. Independent living (IL)"]
[]
[]
[]
["Section VII: Report Submission Authority"]
["1. Unaccompanied Refugee Minors (URM) Provider Agency:"]
[]
["Agency Name:"]
["Address:"]
["City:",{"$nulls":5},"State:",null,null,null,"Zip Code:"]
[]
["Name",{"$nulls":7},"Title",{"$nulls":5},"Agent Approval Date"]
[{"$nulls":14},"(mm/dd/yyyy)"]
["Phone:",{"$nulls":7},"Email:"]
[]
[]
["2. State Agency:"]
[]
["Agency Name:"]
["Address:"]
["City:",{"$nulls":5},"State:",null,null,null,"Zip Code:"]
[]
["Name",{"$nulls":7},"Title",{"$nulls":5},"Agent Approval Date"]
[{"$nulls":14},"(mm/dd/yyyy)"]
["Phone:",{"$nulls":7},"Email:"]
["Approval/Denial Comments:"]