Sheet 1: ORR-5 Sections I&II

	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	
	

		


		


		


		


		


		


		
Refugee Data Submission System for Formula Funds Allocations and Service Analysis (ORR–5): Sections I & II
		


		


		


		


		


		


		


		


		
OMB #: 0970-0043
	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		
Expiration Date: 04/30/2024
	
	

		
SECTION I: BASIC INFORMATION
		
SECTION II: RSS FAMILY SELF-SUFFICIENCY PLAN (FSSP) INITIAL ASSESSMENT AND REFERRAL
		
	

		
1. Alien Number
		
2. Principal Applicant (PA) Alien Number 
		
3. Relationship to PA
		
4. First Name
		
5. Middle Name
		
6. Last Name
		
7. DOB
		
8. Status or Category
		
9. Gender
		
10. Nationality
		
11. Zip Code
		
12. City
		
13. County
		
14. Eligibility  Date
		
15. Migration Status
		
16. Date of Migration
		
17. Refugee Cash Assistance (RCA) Enrollment Date
		
18. RCA 
Exit Date
		
19. Refugee Medical Assistance (RMA) 
Enrollment Date
		
20. RMA 
Exit Date
		
21. Refugee Medical Screening (RMS)
Enrollment Date
		
22. RMS  
Exit Date
		
23. Refugee Support Services (RSS)   
Enrollment Date
		
24. RSS  
Exit Date
		
25. RSS FSSP
 English Ability
		
26. RSS FSSP 
Education Level
		
27.  RSS FSSP 
Initial Primary Goal (G1) 
		
28. RSS FSSP 
Initial Referral Relevant to G1 
	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


		


	
	

		
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN:  Through this information collection, the Office of Refugee Resettlement (ORR) is gathering data to better understand client goals, services utilized, and the outcomes achieved by the population served.  The data will be used to inform evidence-based policy making, and data collected in section I will guide resource allocation.  Public reporting burden for this collection of information is estimated to average 140 hours per grantee, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information.  This is a mandatory collection of information [Immigration and Nationality Act, section 412(a)(3)].  An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number.  If you have any comments on this collection of information, please contact draprograms@acf.hhs.gov.