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["DEPARTMENT OF HEALTH AND HUMAN SERVICES",{"$nulls":13},"OMB No. 0970-XXXX"]
["Office of Refugee Resettlement",{"$nulls":13}," Exp. XX/XX/XXXX"]
[]
["Name of Youth",{"$nulls":10},"Alien Registration No. ",null,null," HHS Tracking No."]
["Last",null,null,null,"First",null,null,null,"Middle"]
[]
[]
[]
[" ORR-4 REPORT FORM"]
["UNACCOMPANIED REFUGEE MINORS (URM) PROGRAM"]
["OUTCOMES REPORT"]
[]
["State Agency",{"$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:",{"$nulls":4},"Zip:"]
[]
["Section I: Report Action"]
[]
["Check the box below to indicate the type of report supported by the Form ORR-4:"]
[]
[null,"1. Annual Outcomes Report"]
[null,"2. Baseline Report--Youth 17 and above and submitted in conjunction with an initial ORR-3 placement report"]
[null,"3. Follow-up Annual Report--Former URM clients who are 17 to 21 years old and have terminated all ORR-funded services (Sections III: Education, Medical Coverage and Personal Functioning, and IV: Family Reunification  Activity, are not required in follow-up reports. Please proceed to Section V)"]
[null,"Youth was able to participate in responding to this ORR-4: ",{"$nulls":6}," Yes","  No"]
[]
["Date data was collected: ",null,null," (mm/dd/yyyy)"]
[null,null,"Age:","?"]
[]
["Section II:  Identifying Data"]
[]
["1. Date of Birth",{"$nulls":7},"2. Sex",null,"Female",null,null,"Male "]
[]
[]
[]
["Section III: Education, Medical Coverage and Personal Functioning of the Youth"]
[]
["1. Education Information:"]
["a.","Indicate the youth's current school grade level:"]
[]
["b.","Check the appropriate box to indicate current school level and any additional curricula as appropriate:"]
[]
[null,null,"Primary "]
[null,null,null,"Regular school program",null,null,null,"Provide additional curricular information:"]
[null,null,null,"Specialized school program"]
[]
[null,null,"Middle "]
[null,null,null,"Regular school program"]
[null,null,null,"Specialized school program"]
[]
[null,null,"Secondary "]
[null,null,null,"College bound "]
[null,null,null,"Vocational "]
[null,null,null,"GED "]
[]
[null,null,"Postsecondary",null,null,"Type of Degree Program:",{"$nulls":5},"Estimated Completion Date:"]
[null,null,"Not in school",null,null,"Explain:"]
[]
["c.","Has the youth required and received any educational remedial services during the reporting period?"]
[]
[null,null,"Yes",null,null,"No",null,"If yes, please specify."]
[]
[]
[]
[]
["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."]
[]
[null,null,"Yes",null,null,"No",null,"If yes, please specify."]
[]
[]
[]
[]
[]
["2. Medical Coverage: "]
[]
[null,"Medicaid",null,null,null,"ORR Funded Medical Coverage",{"$nulls":4},"Other",null,null,null,"None "]
[]
[]
[]
["3. Caseworker/Provider Assessment:"]
[]
["Assess the youth's functioning in the following areas at an age-appropriate level on a scale of 1 through 5, as indicated below. Provide an explanation if necessary."]
[]
[{"$nulls":6},"Poor","Below Average","Average","Above Average","Excellent","Explain"]
[]
["English Language Skill"]
[{"$nulls":6},1,2,3,4,5]
["Education (other than English)"]
[{"$nulls":6},1,2,3,4,5]
["Social Adjustment"]
[{"$nulls":6},1,2,3,4,5]
["Health Condition"]
[{"$nulls":6},1,2,3,4,5]
["Mental Health "]
[{"$nulls":6},1,2,3,4,5]
["Preservation of Ethnic and Religious Heritage"]
[{"$nulls":6},1,2,3,4,5]
["Youth's Adherence to Safety Plan"]
[{"$nulls":6},1,2,3,4,5]
[]
[]
["Section IV: Family Reunification Activity"]
[]
["1. Does the youth have a current permanency plan?",{"$nulls":7},"Yes",null,"No",null,"Emancipated"]
[]
["       Provide the date of the most recent permanency plan review.",{"$nulls":10}," (mm/dd/yyyy)"]
[]
[]
[]
["2. Family reunification efforts in the U.S."]
[" a.  Are any parents or relatives in the U.S. being assessed for reunification?   ",{"$nulls":11},"Yes",null,"No"]
[null,"If Yes, ","provide the following:"]
[]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
[]
[" b.  Have there been any significant developments?",{"$nulls":8},"Yes",null,"No"]
[" If Yes, describe efforts and significant developments: "]
[]
[]
[]
[" c. Has there been an explicit decision, in the past year, to not reunify a youth under 18 with:"]
["  a parent in the U.S.?",null,null,null,"Yes",null,"No",null,null,"a relative in the U.S.?",{"$nulls":4},"Yes",null,"No"]
[null,"Explain any such decisions; include name(s), relationship(s), and reason(s) for not reunifying youth.  "]
[]
[]
[]
[]
[]
[]
["3. Family tracing and reunification with relatives in other countries "]
[" a.  Are any parents or relatives in other countries being assessed for reunification?   ",{"$nulls":11},"Yes",null,"No"]
[null,"If Yes, provide the following:"]
[]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
["Name:",{"$nulls":4},"Relationship:",{"$nulls":5},"Location:"]
[]
[" b. Have there been any significant developments?",{"$nulls":8},"Yes",null,null,"No"]
[null,"If Yes, describe efforts and significant developments: "]
[]
[]
[]
[]
[]
[" c. Has there been an explicit decision, in the past year, to not reunify a youth under 18 with:"]
["  a parent in another country?",{"$nulls":4},"Yes",null,"No","a relative in another country?",{"$nulls":5},"Yes",null,"No"]
[null,"Explain any such decisions; include name(s), relationship(s), and reason(s) for not reunifying youth.  "]
[]
[]
[]
[]
[]
[]
["4.  Communication with family members"]
[" Is youth in communication with parents or relatives, in the U.S. or other countries, with whom reunification is not feasible or appropriate at this "]
["point in time?  ",null,null,"Yes",null,"No"," "]
[null,"If Yes, provide the following, and include siblings or other relatives too young to serve as caregivers: "]
[]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
["Name:",null,null,null,"Relationship:",null,null,null,"Location:",{"$nulls":4},"Frequency:"]
[]
[]
[]
["Section V: Independent Living Services"]
["1. Youth residence:"]
[]
["Address:"]
["City:",{"$nulls":7},"State:",null,null,null,"Zip:"]
[]
[]
["2. Service Type(s):"]
[null,"a. Youth remains in foster care ",{"$nulls":11},"Select funding source"]
[null,"b. Adjudicated delinquent",{"$nulls":11},"ORR","State/ Chafee","Private","NA"]
[null,"c. Special education"]
[null,"d. Independent living needs assessment"]
[null,"e. Academic support"]
[null,"f. Post-secondary educational support"]
[null,"g. Career preparation"]
[null,"h. Employment programs/vocational training"]
[null,"i. Budget and financial management"]
[null,"j. Housing education /home management training"]
[null,"k. Health education & risk prevention"]
[null,"l. Family support & healthy marriage education"]
[null,"m. Mentoring"]
[null,"n. Supervised independent living"]
[null,"o. Room & board financial assistance"]
[null,"p. Education financial assistance"]
[null,"q. Other financial assistance",{"$nulls":5},"Type:"]
[]
[]
[]
["Section VI: Independent Living Outcomes"]
[]
[]
["1. Outcomes reporting status:  "]
[null,"a. Youth participated"]
[null,"b. Youth declined"]
[null,"c. Incapacitated"]
[null,"d. Incarcerated"]
[null,"e. Runaway/missing"]
[null,"f. Unable to locate/invite"]
[null,"g. Death"]
["2. Date of outcome data collection:  ",{"$nulls":5}," (mm/dd/yyyy)"]
[]
[]
[]
[]
["Data Elements ",{"$nulls":5},"Queries",{"$nulls":5},"Responses"]
[]
["3. Foster care status - outcomes: ",{"$nulls":11},"Yes","No","Declined","NA","Don't Know"]
[null,"Youth remains in foster care"]
["4. Current full-time employment",{"$nulls":5},"Are you currently employed full-time?"]
["5. Current part-time employment",{"$nulls":5},"Are you currently employed part-time?"]
["6. Employment-related skills",{"$nulls":5},"In the past year, did you complete an apprenticeship, internship or other on the job training, either paid or unpaid?"]
["7. Social Security",{"$nulls":5},"Are you currently receiving SSI, Disability or other dependents' payments?"]
["8. Educational aid",{"$nulls":5},"Are you currently using a scholarship, grant, stipend, student loan, voucher or other education financial aid to cover educational expenses?"]
["9. Public financial assistance",{"$nulls":5},"Are you currently receiving ongoing welfare [State TANF] payments to support your basic needs?"]
["10. Public food assistance",{"$nulls":5},"Are you currently receiving public food assistance [SNAP or community program]?"]
["11. Public housing assistance",{"$nulls":5},"Are you currently receiving any sort of public housing assistance?"]
["12. Other financial support",{"$nulls":5},"Are you currently receiving any periodic and/or significant financial resources or support from another source not previously indicated and excluding paid employment?"]
["13. Highest educational certification received",{"$nulls":5},"What is the highest educational degree or certification that you have received?"]
[null,"a. GED"]
[null,"b. high school diploma"]
[null,"c. vocational certificate"]
[null,"d. vocational license"]
[null,"e. associate's degree"]
[null,"f. bachelor's degree"]
[null,"g. higher degree"]
[null,"h. none of the above"]
["14. Current enrollment and attendance",{"$nulls":5},"Are you currently enrolled in and attending high school, GED classes, post-high school vocational training or college?"]
["15. Connection to adult",{"$nulls":5},"Is there currently at least one adult in your life, other than your caseworker to whom you can go for advice or emotional support?"]
["16. Homelessness",{"$nulls":5},"Have you ever been homeless at any time?"]
["17. Substance abuse referral",{"$nulls":5},"Have you ever referred yourself or has someone else referred you for an alcohol or drug abuse assessment or counseling?"]
["18. Incarceration",{"$nulls":5},"Have you ever been confined in a jail or other correctional facility or juvenile detention in connection with allegedly committing a crime?"]
["19. Children",{"$nulls":5},"Have you ever given birth or fathered any children that were born?"]
["20. Marriage at child's birth",{"$nulls":5},"If yes, were you married to the child's other parent at the time?"]
["21. Medicaid",{"$nulls":5},"Are you currently on Medicaid [or use the name of the State's medical assistance program under title XIX]?"]
["22. Other health insurance coverage",{"$nulls":5},"Do you currently have health insurance other than Medicaid?"]
["23. Health insurance type: Medical",{"$nulls":5},"Does your health insurance include coverage for medical services?"]
["24. Health insurance type: Mental health",{"$nulls":5},"Does your health insurance include coverage for mental health services?"]
["25. Health  insurance type: Prescription drugs",{"$nulls":5},"Does your health insurance include coverage for prescription drugs?"]
["26. Health insurance type: Other",{"$nulls":5},"Does your health insurance include coverage for other services, e.g., dental or vision"]
[{"$nulls":9},"Other type of coverage:"]
[]
[]
[]
["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",{"$nulls":5},"Date (mm/dd/yyyy)"]
[]
["Phone:",{"$nulls":7},"Email:"]
[]
[]
["2. State Agency:"]
[]
["Agency Name:"]
["Address:"]
["City:",{"$nulls":5},"State:",null,null,null,"Zip Code:"]
[]
["Name",{"$nulls":7},"Title",{"$nulls":5},"Date (mm/dd/yyyy)"]
[]
["Phone:",{"$nulls":7},"Email:"]
["Approval/Denial Comments:"]