ORR Unaccompanied Children Program Policy Guide: Section 5

5.1 Responding to Inquiries from the Media

ORR has policies in place to ensure that ORR and ORR funded care providers consider the best interests of unaccompanied alien children when responding to inquiries from the media. As a federally funded program, ORR is committed to public transparency and accountability. As a service provider, we are committed to protecting the privacy and safety of the children in our care. Accordingly, ORR requires that grantees make a case-by-case evaluation of each media inquiry in a timely manner, while recognizing the overarching mission of providing for the physical and mental well-being of unaccompanied alien children in our care.

ORR funded care providers may be approached by members of the media for background information, requests for interviews with staff and unaccompanied alien children, and requests for tours of the facility. ORR grantees can respond to any and all media inquiries about their organization and any of the organization’s activities as described in 5.1.1. ORR works with the ACF Office of Public Affairs (OPA) to address media requests that are outside the scope for care providers as described in 5.1.2.

Posted 3/16/15

5.1.1 Policies for ORR Grantees
When handling requests from the media, the following standards apply to grantees:

• The care provider organization may discuss activities of their own organization, but not those of other grantees For questions about ORR or its programs, or about Federal or administration policy related to unaccompanied alien children, the reporter should be referred to the ACF Office of Public Affairs at 202-401-9215.
• In order to ensure the privacy and security of the children in its care, ORR and its grantees do not discuss specific cases or individuals with members of the media or others.
• Addresses of shelters must not be published or publicized. If a reporter obtains an address by other means, the organization should explain the security reasons for not publishing those addresses. Grantees may not have media at shelters, or arrange for tours or visits without going through ORR. (Requests for facility tours will be handled by ORR as described in 5.1.4 in a manner to protect the security and privacy of the unaccompanied alien children and with minimal disruption to the program).

In addition to these policies, ORR recommends that care providers use “best practices” in media relations. These include: developing talking points, which help representatives of an organization communicate clearly and effectively with the media; directing the media to the ORR website and other resources for more information about ORR’s UAC Program; and preparing individuals who are handling press inquiries to answer the most common questions and respond in ways that effectively communicate the organization’s achievements and contributions. Facilities experiencing a high volume of inquiries or facing difficulties in responding to complex requests should contact ORR. U.S. Department of Health & Human Services Terms of Service and Privacy Policy. **WARNING**WARNING**WARNING**. This warning banner provides privacy and ...

Revised 4/20/15

5.1.2 How ORR Responds to Press Inquiries

ORR care providers may receive inquiries on topics outside their expertise and authority or that would not meet the standards described above. These inquiries may include questions about ORR policies, activities at the national level, requests to interview specific unaccompanied alien children, and requests for data, such as the number of children in ORR care, names, nationalities, background and other aggregate information about the program. In those instances, ORR care providers must forward these requests to their ORR Project Officer (PO), with a copy to the ORR Federal Field Specialist (FFS) and ORR communications staff. ORR then works with the Office of Public Affairs (OPA) to provide to the media an official, up-to-date and accurate response. During an influx, ACF may create special procedures to address the high volume of inquiries. Policy Statements. HHS Policy for Records Management · HHS Policy for Improving Race and Ethnicity Data - ACTION. Administrative Staff Manuals. HHS ...

Posted 3/16/15

5.1.3 Requests to Interview a Specific Child

To safeguard the privacy and well-being of unaccompanied alien children in ORR care, it is ORR’s policy to decline requests by the media to interview youth in ORR custody. In exceptional circumstances, ORR may consider a media request for an interview with a particular child and will evaluate the following factors in conjunction with OPA prior to making a decision about allowing the press to interview a specific child.

• Is the interview in the best interest of the child? (taking into consideration the child’s placement, mental health situation, education, physical condition, culture, background and family in the United States) ORR Unaccompanied Children Program Policy Guide
• Is the child represented by counsel? If yes, does the attorney support an interview with the press?
• Does the DHS believe there may be an adverse impact on the child’s immigration case?
• Will the interview be disruptive to the facility or other children in the facility?
• Will special arrangements be needed? (e.g., interpreter, security)
• How will the interview be conducted (e.g., video, phone)? How long will the interview be?
• Are there preferable alternatives?

Posted 3/16/15

5.1.4 Requests to Visit a Facility

The press may want to see a facility but not speak with the children.

To maintain the privacy, security and well-being of the children, we generally do not do media tours of facilities when children are present.

However, in certain circumstances, ORR will consider a request and evaluate the following factors in conjunction with OPA prior to making a decision about allowing the press to visit a particular facility. Freedom of Information Act (FOIA) | Office of Inspector General | U.S. ...

• To what extent will the visit be disruptive to the facility or children in the facility?
• Will special arrangements be needed? (e.g., security)
• How will the visit be conducted? (e.g., interviews with facility staff, number of reporters) How long will the visit be?
• Are there preferable alternatives?

Posted 3/16/15

5.1.5 Requests for General Information and Data

The media may ask for general information and data about the program, such as the number of youth in ORR’s care, and the names, nationalities and backgrounds of children. ORR releases a wide range of data that is posted to the ACF website. This data includes number of children in the program, aggregate information on country of origin, and county-level data for counties where more than 50 children have been released. Grantees may always refer media or others to this website: anandihospital.com/programs/orr/programs/ucs/about. ORR does not release the names of unaccompanied alien children or other private, identifying information. In addition, ORR generally does not allow photographs or videos to be taken that could reveal the identity of a youth in ORR care. OPA can provide still and, in some cases, video images of facilities for the media to use.

Posted 3/16/15

5.2 ORR Policies on Requests to Tour ORR Care Provider Facilities

Interested parties who wish to visit a care provider facility must request a tour through ORR. ORR considers various factors when responding to these requests as described in Section 5.2.1 Evaluation Criteria with the best interests of the child of paramount importance. Web Records Policy and Guidance

A tour is a presentation of the physical ORR care provider facility, accompanied by program staff. A tour does not include interactions with children at the facility unless previously approved. Tours may be requested by advocacy groups, faith-based organizations, researchers, government officials, and other relevant stakeholders.

A visit refers to an approved party meeting with specific children in ORR care. Visits do not involve a tour of the facility.  A visit may be requested by family members, potential sponsors, legal representatives, child advocates, or consulate officials.

• For policies governing visits by family members and potential sponsors, refer to Section 3.3.10 Telephone Calls, Visitation, and Mail.
• For policies governing visits by consulate officials, refer to Section 5.4.4 Visitation.
• Litigation related visits must be arranged through ORR’s Division of Policy and Procedures.

Tours are generally not approved for attorneys (unless the attorney is plaintiff’s counsel to an existing settlement and the tour is pursuant to the terms of the settlement, in which case the terms of the settlement set forth the requirements). If the attorney is interested in providing legal services for unaccompanied children (UC), contact information should be requested from the attorney and provided to UC Legal Services at [email protected].

For media requests  refer to section 5.1 Responding to Inquiries from the Media.

Revised 9/18/2023

5.2.1 Evaluation Criteria

ORR uses the following criteria to evaluate the tour request:

1. Requestor has a legitimate mission or business purpose for participating in a tour (e.g. State, local government matter, child welfare advocacy, legal issue, etc.).
2. The privacy and well-being of children at the care provider facility will not be adversely affected by the tour.
3. There are sufficient staffing and ground resources to conduct the tour and protect the privacy and well-being of children. ORR will also consider the number of visitors subject to the request. This inclusion policy applies to HHS program administrative records ... HHS data systems collect ... rules and regulations of the Office of Personnel Management).
4. There is sufficient notice of a request. Requests should be submitted two weeks prior to the tour. Requests not received within this time frame may be considered if there are exigent circumstances. Web records are written or electronic materials that document what we said, did, andhow we did it. Simply put, by law Web managers need to maintain Web records.

Revised 9/18/2023

5.2.2 Special Arrangements

Special arrangements, such as additional security and accessibility issues, may be necessary for certain types of tours. Such arrangements must be included in the submitted request and will be coordinated prior to the approved tour. Requests which include access to specific individuals, such as care provider staff or children, during the visit will be coordinated with the ORR/FFS. Any specific individual who the requestor wishes to speak with during the tour must be identified in the request. ORR will only approve such requests if it is consistent with the best interest of the children in care. HHS Human Capital > Mandatory Employee Training

Revised 9/18/2023

5.2.3 Protocol for Tours of Care Provider Facilities

All parties interested in touring an ORR care provider facility must submit the UC Tour Request Form to the UC Tour Request inbox at [email protected]. Litigation related tours must be arranged through ORR’s UC Policy Unit. Flores Council visits will be coordinated through DOJ and the FFS following ORR procedures.

All tours must be conducted in a manner that is consistent with ORR’s legal and child welfare obligations to treat all children in care with dignity, respect, and special concern for their vulnerability as unaccompanied children. The ORR Unaccompanied Children Program Policy Guide is a summary of ORR policies for the placement, release and care of unaccompanied children in ORR custody. The guide is for members of the public and other stakeholders and is organized into three main sections.

Approved tour participants may tour standard facilities (shelters, residential treatment centers, staff secure and secure facilities, etc.) and temporary emergency facilities (e.g., influx care facilities). Tours must be conducted in accordance with ORR’s policies and procedures, as well as the internal policies and procedures of the individual care provider facility.

The maximum number of participants in any tour of a facility is six adults, including interpreters and others acting in a support capacity. When submitting a request, each individual should identify their professional connection to the UC Program’s mission and any organization(s) for which they work or volunteer. Visitors whose names are not provided in advance of the visit may not be accommodated.

Tours must:

• Take place during normal business hours and  last no longer than one and a half hours.
• Be conducted in a manner that minimizes disruption to the normal functioning of the care provider facility.
• Not interrupt routine activities such as mealtimes and scheduled activities.

Tour Participants must:

• Be sensitive to staff responsibilities.
• Always stay with their ORR federal guide.
• Not interact with staff or children unless specifically approved beforehand.
• Always demonstrate appropriate adult role-modeling (e.g., conveying respect and empathy toward others, including facility staff, in words and actions), as children may be observing the visit.  
• Respecting the privacy of children and staffs personal effects and documents- Not search cabinets, drawers, the personal belongings of staff and children, and other unauthorized areas operated by the care provider facility, which may contain sensitive information about the children in care.
• Not share, identifying information, such as the care provider facility’s physical address, with individuals who are not part of the tour.

ORR does not allow any type of recording device, including phones and cameras, inside the care provider facilities during tours.

ORR reserves the right to terminate a tour if any tour participant violates this tour protocol policy, other ORR policies, or the care provider facility’s policies and procedures.

Additional protocol or exceptions may apply to the following groups:

1. Legal representatives (i.e. Flores counsel, legal service providers);
2. Child advocates including Protection and Advocacy Systems (P&A) (see Section 5.2.5 Protection and Advocacy System Visits);
3. Consulate Officials 
4. Members of Congress (Section 5.2.4 Congressional Tours)
5. Groups conducting oversight and investigations ( i.e. HHS’ Office of Inspector General; law enforcement, etc.)

Revised 9/18/2023

5.2.4 Congressional Visits

Members of the United States Congress (that is, members of the United States House of Representatives and the United States Senate) may, for the purposes of conducting oversight, tour ORR care provider and influx care facilities, provided: Policy Statement on Inclusion of Race and Ethnicity in Dhhs Data Collection Activities

• Members of Congress coordinate the oversight visit with ORR no less than two business days prior to the visit. This time frame ensures that operations at ORR facilities will not be disrupted and that Congressional visits do not interfere with the child welfare and child safety operations of the facility.1
• Members of Congress, upon request, shall provide official, government-issued photo identification to show that the visitor is a member of Congress (such as a Congressional I.D. card). ... employees. 2024 Records Management, 10/01/2024, 12/31/2024, Annual, All Required (OpDiv Specific Guidance). Messages · LMS Orientation.
• Staff accompanying any elected official must show current identification from the respective legislative body to confirm they serve in an official governmental role for an elected official. In both these roles she provides leadership across HHS Operating Divisions and Staff Divisions that ensures data collection and records management compliance ...

Congressional staff, including those from a member’s office, are required to adhere to the general requirements of Section 5.2 ORR Policies on Requests to Tour ORR Care Provider Facilities, including the requirement to submit a request two weeks prior to the visit, unless they are accompanying the member of Congress.

Revised 9/18/2023

5.2.5 Protection and Advocacy System Tours and Visits

Protection and Advocacy Systems (P&As) exist in each U.S. state, the District of Columbia, and five U.S. territories, as well as for Native Americans residing in the four corners region (southwest Colorado, southeast Utah, northeast Arizona, and northwest New Mexico) to protect the rights of individuals with disabilities. These systems are independent of service-providing agencies and provide legal representation, protection, advocacy, and assistance, to individuals of that State or Territory with a disability. The purpose of this Policy is to establish the principles, responsibilities, and requirements for managing HHS records.

A P&A may seek reasonable unaccompanied access to standard facilities and temporary emergency facilities (e.g., influx care facilities). This access is for the purpose of: (ii) Federal Bureau of Investigation criminal history records, including fingerprint checks. (2) A program has 90 days after an employee is hired to complete ...

1. Providing information, training, and referral for programs addressing the needs and rights of individuals with disabilities;
2. Monitoring compliance with respect to the rights and safety of individuals with disabilities;
3. Inspecting areas of a facility used by or are accessible to children with disabilities; and
4. Investigating a facility based on a complaint or with probable cause of abuse or neglect.

Access to facilities

Access to ORR care provider facilities must be reasonable and afforded immediately upon request. It is reasonable for P&As to provide advance notice for informational and advocacy purposes. For purposes of monitoring, inspection, and investigation, a P&A, at its discretion, may provide advance notice of its intent to visit by contacting the care provider, but it is not required. Reasonable, unaccompanied access may take place outside normal business hours in for investigative purposes when a complaint has been filed or the P&A has probable cause for abuse or neglect. 

P&As must have reasonable unaccompanied access to areas within a standard or temporary emergency facility that are used by or accessible to individuals with disabilities. The P&A may inspect, view, and photograph these areas. HHS AMS

Access to Children with Disabilities

Care providers must provide reasonable unaccompanied access to any individuals with a disability in ORR facilities.

Unless the P&A is responding to a complaint about, or has probable cause of abuse or neglect, the P&A should schedule interviews with children prior to the visit. Interviews should be held at reasonable times that do not interrupt the child’s daily routine. A child may refuse the interview or end the interview at any time.

P&As may not photograph or video record any residents at ORR facilities without consent.

Response to a complaint with probable cause

P&As are not required to provide advanced notice of visits in response to a complaint or probable cause of abuse or neglect.

P&As may interview any unaccompanied child or facility resident, employee, or other persons, including the person thought to be the victim of abuse, who might be reasonably believed by the P&A to have knowledge of the incident under investigation. Children have the right to deny an interview request or terminate an interview at any time.

Access to Records

ORR will provide access to the records of children with disabilities to a P&A when such access is authorized, and the request is made appropriately under, the federal authorities governing disclosures to P&As. P&As follow strict confidentiality requirements. Any records collected by a P&A will not be used or disseminated inappropriately.

5.3 Testimony by Employees and Production of Documents Where the United States is Not a Party

Information about requesting the testimony of an ORR employee or production of documents where the United States is not a party is available at 45 CFR Part 2 .

Posted 3/30/15

5.3.1 Care Provider Testimony and Views

ORR care provider staff should follow their organization’s policy regarding testimony. This may include talking to the care provider’s attorney. If care provider staff do testify, they must make clear that they do not represent ORR and that their testimony does not reflect the opinion or position of ORR.

Posted 3/30/15

5.3.2 Confidentiality of Information

Care providers must maintain the confidentiality of children’s information, and must protect it from unauthorized disclosure. Therefore, as a general matter, they may not reveal client information in affidavits or testimony, where not legally required to so, and without ORR approval. However, care providers may allow a youth 14 and older, who wishes the staff to testify or provide a declaration, to consent, in writing, to the testimony, and then ORR could approve the disclosure of the confidential information.

For children younger than 14, or who do not have the capacity to consent, the care provider should seek the written consent of the child’s parent or legal guardian in order to include confidential information in an affidavit or written or verbal testimony. If such consent is not available, the care provider should contact ORR.

Posted 3/30/15

5.3.3 Prohibition on Release of Records Without Prior Approval

The records of unaccompanied alien children are the property of ORR, and care providers may not release records without prior approval from ORR.

Revised 08/07/2023

5.4 ORR Policies on Communication and Interaction with Consulates

ORR and its care providers must follow consulate notification protocols established under international and federal law.  Under most circumstances, ORR must notify an unaccompanied child’s consulate that the child is in ORR custody and provide the location of the ORR care provider facility. Unaccompanied children must have reasonable access to consulate officials, and in some cases may be required to meet with consulate officials at the request of the consulate.  ORR’s policies cover notification, access, visitation, and documentation of contact with consulates.  HHS Policy for Records Management

Revised 9/18/2023

5.4.1 Notifications to Consulates

How does ORR notify consulates that their citizens are in ORR custody?

• Children from countries requiring Mandatory Notification²
  
  If the youth is from a country requiring mandatory notification, the care provider working with their ORR/FFS must notify the child’s consulate as soon as practicable.  The care provider must notify the consulate even if notification is against the child’s wishes. If the youth or child is claiming credible fear or seeking asylum, the care provider must still notify the consulate that the child is in ORR custody; however, under no circumstances should a care provider, ORR/FFS, or other stakeholder notify the consulate that the child is claiming credible fear or seeking asylum.
• Children from countries NOT requiring Mandatory Notification
  
  If the youth is from a country not requiring mandatory notification, the care provider is not required to notify the consulate. However, if a particular consulate or region has made a formal request for standing notification of its citizens, ORR may, in its discretion, instruct the care provider to provide notice on terms agreed to between ORR and the consulate.  For example, ORR and a consulate may agree on the frequency of notifications and the information provided, balancing the consulate’s need for information about its citizens and ORR’s need to ensure the effective functioning of the program and the privacy of the children.  Even if ORR has entered into an agreement with a consulate, the care provider and ORR/FFS may not under any circumstances share the name of a child or any other information about a child claiming credible fear or seeking asylum from a country not requiring mandatory notification. Our Team

Posted 4/27/15

5.4.2 Unaccompanied Children’s Right to Contact and Visit with their Consulate

During the admission orientation (within 48 hours of arrival into care), the care provider must inform unaccompanied children of their right to contact their consulate and give each child reasonable access to a telephone and contact information for their consulate.  If a child requests to visit with a consulate official, the child’s Case Manager will arrange, with the consulate, a time to visit with the child at the care provider facility.

Revised 9/18/2023

5.4.3 Consulate Officials: Access to Their Citizens and ORR Care Provider Facilities

To meet with a child in ORR care, consulate officials must make a request though a child’s case manager.   Consulate access to a child depends on whether the child is from a country requiring “mandatory notification” or a country NOT requiring “mandatory notification.”

• Children from countries requiring mandatory notification:

If the child is from a country that requires mandatory notification, the care provider makes arrangements for the visit as soon as reasonably possible, regardless of whether the child wishes to meet with the consulate official.  This is true even if the child is claiming credible fear or seeking asylum.

• Children from countries NOT requiring mandatory notification:

If the child is from a country not requiring mandatory notification, the care provider must attempt to make contact with the child’s parent or legal guardian to seek permission for the child to meet with a consulate official.3 However, if the parent or legal guardian is unavailable or unable to respond within 72 hours of the request, the care provider may presume the visit is authorized, unless the child objects or is claiming credible fear or seeking asylum, in which case, the care provider must deny access to the specific child.

What if consulate officials wish to tour a facility, but not meet with a particular child?
Consulates requesting to tour ORR care provider facilities or meet with program staff, must submit a UC Tour Request Form to the UC Tour Request inbox at [email protected].   For more information on ORR care provider facility tour requests, refer to Section 5.2 ORR Policies on requests to Tour ORR Care Provider Facilities.

Can consulate officials bring other adults with them  to tour a care provider facility?
If consulate officials wish to bring non-consulate officials, such as foreign dignitaries or third-parties, they must include all tour participants when submitting a tour request following ORR’s care provider facility tour policies described in Section 5.2 ORR Policies on Requests to Tour ORR Care Provider Facilities, including limitation of six adults or fewer for each tour request. ORR will evaluate the request as described in the policy.

Revised 9/18/2023

5.4.4 Visitation

Case Managers will arrange for consular visits by providing a private space for the consulate official and the unaccompanied alien child to meet. The visits will follow the care provider’s general time, place and manner restrictions regarding visits so as to minimize the disruption to care provider facility operations.

Posted 4/27/15

5.4.5 Information Requests

If consulate officials want to receive information on children in ORR care (other than whether the children are currently placed at a particular ORR care provider facility) they must make a request to ORR.  ORR, in its discretion, may approve or deny the request. In making a decision, ORR takes into consideration the availability of the information and the children’s privacy concerns.  As a general policy, ORR does not release private information, such as medical and mental health records, unless the child provides consent.

Posted 4/27/15

5.4.6 Documentation

Care providers must maintain documents in individual unaccompanied alien child case files regarding requests for access to individual children and meetings between children and their consulate. Case Managers must document this information in Case Manager notes. 
Care providers must maintain documents of general visits or other requests from consulates that are not specific to individual children.

Posted 4/27/15

5.4.7 ORR and Consulate Joint Activities

ORR partners with foreign consulates in a number of areas including:

• The authentication of foreign documents, such as birth certificates.  ORR or its care providers may contact consulates to authenticate documents to assist in age determinations and the establishment of familial relationships between youth and potential sponsors.
• Family tracing activities.  Through family tracing activities, consulates often assist Case Managers so that unaccompanied alien children can communicate with their families in their home countries.  This assistance is critical to the work of Case Managers, especially when a child’s family is located in remote or rural towns that lack telephone access, or cases where the youth’s family is unknown or the child is too young to communicate.
• Provision of information related to crimes to which the UAC may be a perpetrator, witness or victim in their home country.  When consulates are able to assist ORR in locating this information, it informs ORR’s decisions concerning placements, services and release options.

Posted 4/27/15

5.5 ORR Monitoring and Compliance

This section covers ORR’s monitoring activities, the roles and responsibilities of ORR staff, foster care monitoring, and care provider internal monitoring activities.

ORR conducts monitoring visits at least monthly to ensure that care providers meet minimum standards for the care and timely release of unaccompanied alien children, and that they abide by all Federal and State laws and regulations, licensing and accreditation standards, ORR policies and procedures, and child welfare standards.  ORR increases the frequency of monitoring if it is warranted by issues identified at a facility.  In addition, if ORR monitoring finds a care provider to be out of compliance with requirements, ORR issues corrective action findings and requires the care provider to resolve the issue within a specified time frame. ORR also provides technical assistance, as needed, to ensure that deficiencies are addressed.

As described below, the corrective action is the cornerstone of ORR’s monitoring policy. These corrective actions are issued at any time as a result of ORR’s various monitoring activities. The combined expertise of the ORR team allows for field staff to report on-the-ground findings, particularly in areas of licensing and cases involving specific children, and for program staff in headquarters to evaluate issues related to budget, program management, and risk assessment.

ORR’s overall goal is always to ensure the care and safety of unaccompanied alien children in its custody.  Therefore, ORR may discontinue funding, halt placements and remove children from a facility, and/or close programs that fail to address findings needing corrective action in a timely and effective manner. ORR’s notification procedures and monitoring activities provide for an immediate response involving safety and security issues.

Posted 6/15/15

5.5.1 ORR Monitoring Activities

ORR monitoring is an ongoing, multi-layered process that provides consistent oversight of all components of a care provider’s program, including program design, management, services, safety and security, child protection, case management, personnel management, stakeholder relations, and fiscal management. The monitoring policies addressed in this section are those that create formal accountability standards and check points at regularly scheduled intervals.

ORR monitoring activities include the following:

• Desk Monitoring: Ongoing oversight based on the HHS grants management model, which includes monthly check-ins with the care provider’s Project Officer (PO), regular record and report reviews, financial/budget statements analysis, and communications review.
• Routine Site Visit Monitoring:  Day long visits to every facility on a once or twice monthly basis, both unannounced and announced, to review policies, procedures, and practices and guidelines compliance.  Generally, these visits are limited to review of case management services.
• Site Visits in Response to PO or Other Requests: Visits for a specific purpose or investigation, for example, in response to a corrective action plan.
• Monitoring Visits: Week long monitoring to the site not less than every two (2) years to conduct a comprehensive review of the program.

Desk Monitoring
Desk monitoring refers to ongoing oversight from ORR headquarters. Desk monitoring includes regular reviews of records and reports, such as annual goals and objectives, quarterly program reports, Significant Incident Reports (SIRs), ORR reports about the timely and accurate use of the UAC Portal Database, and financial reports. It also includes regular calls with care provider Program Directors and others, to become knowledgeable about the infrastructure and management systems of the individual programs and to review data found in required documents and reports.  To ensure compliance with policies and procedures and to follow-up on SIRs, ORR staff also request facility case files and spot check them for accuracy and completeness.

Routine Site Visits
ORR staff conducts routine day long site visits at least once a month at each facility to observe service delivery and to review records and procedures. During site visits, ORR representatives attend “case staffings” (meetings that take place with care provider staff, Case Coordinators and others, where individual UAC cases are discussed) at care provider facilities to observe how care provider teams are collaborating and the effectiveness of the case management system as a whole. ORR receives monthly reports on all care provider facilities based on the findings from these site visits as well as quarterly reports on each facility identifying strengths and weaknesses, identified concerns and training needs.

All issues from desk monitoring or site visits that concern safety or security issues or otherwise need elevation are reported to ORR supervisors immediately.

Monitoring Visits
The monitoring visit, conducted not less than every two years, consists of a comprehensive inspection based on information submitted by the care provider prior to the visit and during the visit and interviews with staff, unaccompanied alien children, and stakeholders. The formal monitoring visit utilizes templates and checklists and other tools that must be completed at each site. The last step in the process is ORR’s submission of a monitoring report to the provider (30 days after the visit) with a list of corrective actions that must be addressed. A corrective action is any finding that indicates noncompliance with explicit policies or procedures defined by ORR. The care provider has up to 30 days to submit a response to the corrective action plan, indicating how the program has corrected or will remedy any noncompliance. However, ORR may require more immediate action when appropriate and will notify the care provider.

Prior to the Monitoring Visit, the care provider must provide to ORR written responses to standardized questions about their operations (the Site Visit Guide), including questions on internal quality assurance practices, child protection, case management, health, education, and other services, and administration and financial management. As detailed below, care providers also provide documents to ORR prior to the visit and during the visit.

Relevant documents, reports, and files examined prior to and during a monitoring site visit include but are not limited to:

• Grant application/cooperative agreements
• Completed answers to the Site Visit Guide
• Recent organizational chart of facility staff
• Educational curriculum and weekly class schedule
• Food services/menus, and applicable employee food safety certification
• Facility lease
• Copies of applicable State and local licenses, State licensing requirements (or links to those requirements) and recent State licensing inspection reports
• Recent Audit Report and Financial Status Report
• Recent vehicle inspection
• Safety and sanitation certificates—Fire inspection report
• Quality assurance procedures and internal monitoring resources
• Most recent Quarterly Report
• Current approved Fiscal year budget
• Recent SIRs
• Reports from previous monitoring visits (including corrective action plans) and site visit reports by other ORR staff or contractors.
• UAC case files
• Care provider staff personnel files
• Care provider’s internal policies and procedures
• Care provider’s UAC grievance policy, and copies of UAC grievances
• Materials and reports about the provider’s timely and accurate use of the UAC Portal Database

The week-long Monitoring Visit includes, but is not limited to, standardized interviews with the lead teams of every program component (for example, the Lead Teacher, Lead Clinician) as well as the Program Director, stakeholders (such as the local Legal Service Provider, the Case Coordinator, the Medical Provider, non-HHS Federal agency partners, and others) and unaccompanied alien children. The visit includes a thorough inspection of the physical facility. As with any monitoring activity, care providers must comply with ORR requests for access to the physical facility, program information and case files.

Each site visit generally involves the review of 3-15 randomly chosen case files and related documentation; review of personnel files, review of related documents from the list above; and review of submitted SIRs and internal incident reports from the care provider.

In secure care facilities, the Monitoring PO will review the Further Assessment Swift Track (FAST) Assessment information (used to reevaluate the placement of youth in secure care facilities) in the case file to make sure youth placed in secure care are assessed every 30 days for the possibility of a transfer to a less restrictive setting.

The Monitoring PO consults with the assigned Project Officer, FFS, Case Coordinator, CFS, and DCS Medical Coordinator and meets with the PO and FFS to discuss any findings and any positive or negative trends identified.

ORR monitoring and compliance responsibilities are divided among the teams noted in the table below. The teams work collaboratively but also independently in order to provide a higher level of scrutiny and focused attention on various tasks.

Roles and Responsibilities in ORR Monitoring and Compliance Model

Posted 6/15/15

5.5.2 Follow Up and Corrective Actions

If a care provider is found to be out of compliance with ORR policies or procedures based on monitoring activities, ORR will communicate the concerns in writing to the Program Director or appropriate person through a written monitoring or site visit report, with corrective actions and child welfare best practice recommendations. The need for a corrective action occurs when the care provider is in noncompliance with explicit ORR policy and procedures.

The following table summarizes how the ORR corrective action team divides up responsibilities to make sure that all areas are reviewed for each care provider.

Posted 6/15/15

Following the issuance of corrective actions, the PO or FFS will request a response to the corrective action findings from the Program Director and determine a time frame for resolution and the disciplinary consequences for not responding within the required timeframes.

The care provider’s corrective action plan must include:

• The cause of noncompliance, because effective corrective action cannot be taken without first making a determination of the cause of noncompliance;
• Clear and concise statements of corrective actions (include person/s responsible and timelines);
• Thorough descriptions of corrective actions that reference specific documents, procedures, etc.;
• The date of completion of the corrective actions; and
• Evidence supporting the claim that a corrective action has been fully and effectively implemented and that the corrective action has been performed in the way that it was described.

For more information about the termination of grants and enforcement, see 45 CFR Part 74 .

Posted 6/15/15

5.5.3 Foster Care Monitoring

Care providers who provide care and services for unaccompanied alien children through a sub-contract or sub-grant with a foster care home are responsible for conducting annual monitoring or site visits of the sub-recipient, as well as weekly desk monitoring. This includes evaluating the recipient’s compliance with applicable Federal, State and local laws. Upon request, care providers must provide findings of such reviews to the designated ORR PO.

To assess care providers with foster home arrangements, ORR evaluates and monitors the care provider on-site and through desk monitoring, but may also conduct monitoring at foster homes, as necessary.

Care providers with foster home arrangements are subject to the same monitoring schedule as other care provider facilities but the activities are tailored to the foster care arrangement. For example, ORR Monitors, during on site monitoring visits, may schedule a visit with the grantee staff of a particular foster care home to conduct a first-hand assessment of the home environment and the care provider oversight of the home.

See also Section 4: Preventing, Detecting, and Responding to Sexual Abuse and Harassment, 4.3.5 Disciplinary Sanctions and Corrective Actions.

Posted 6/15/15

5.5.4 Abuse Review Team

In addition to the routine monitoring process, ORR has an Abuse Review Team (ART) that quickly reviews allegations of abuse that are particularly serious or egregious in nature.  The team is composed of ORR staff with the appropriate expertise to assess these allegations, including members of ORR’s Monitoring Team, the Division of Health for Unaccompanied Children, and ORR’s Prevention of Sexual Abuse Coordinator. 

The ART evaluates and conducts a desktop monitoring of all allegations that fall into one of the categories below. ORR leadership may also ask the ART to review other abuse allegations of particular interest. 

• Sexual abuse of an unaccompanied child by a staff member or other adult as defined at 45 CFR 411.6; 
• Sexual abuse of an unaccompanied child by another unaccompanied alien child as defined at 45 CFR 411.6, with the exception of allegations involving intentional touching; 
• Physical injury of an unaccompanied child by a staff member or another unaccompanied alien child that includes lacerations, fractured bones, burns, internal injuries, severe bruising or serious bodily harm; 
• Negligent treatment of an unaccompanied child or children that includes failure to provide adequate food, clothing, or shelter so as to seriously endanger the physical health of the child; 
• Inappropriate use of discipline, including corporal punishment, that result in humiliation, mental abuse, or punitive interference with the daily functions of living, such as eating or sleeping;4 
• Negligent treatment of an unaccompanied child or children that includes failure to provide routine or urgent medical, mental, or dental care, and necessary medications, so as to seriously endanger the physical or mental health of the child; 
• Inappropriate use of health interventions, including quarantine, isolation, physical or chemical restraints, or delayed discharge.  

In addition to desktop monitoring, the ART may identify measures that are necessary to ensure the safety of the children and youth in the care provider facility where the allegation occurred. These measures may include: 

• On-site monitoring of the care provider where the allegation occurred conducted by members of the ART; 
• Monitoring of the corporate offices to review internal policies and reporting structures,  as well as supervisory response to events; 
• Limiting new placements of unaccompanied children at the care provider facility; 
• Stopping placement at the care provider facility where the allegation occurred; 
• Removing all minors in the unaccompanied children program from the care provider facility and placing them into other local care provider facilities; 
• Issuing corrective actions; or 
• Closing the care provider facility. 

Revised 08/02/23

5.5.5 Care Provider Internal Program Monitoring, Evaluation, and Quality Assurance

Care provider facilities must have their own internal monitoring processes that may be set by the care provider’s organization and the professional accreditation agency with which they are associated or by which they are licensed.

Care providers are expected to conduct internal monitoring, evaluation, and continuance quality assurance assessments on a quarterly basis in order to identify areas in need of improvement and/or modification. The care provider’s monitoring, evaluation, and quality assessment plan must include measures to evaluate how the facility:

• Complies with Federal laws and regulations, ORR policies and procedures, and state and local licensing requirements
• Fulfills the program’s Statement of Work with ORR as well as the terms of the  cooperative agreement or contract
• Identifies issues subject to corrective action plans
• Fulfills requirements for any affiliate accreditation agency, if applicable
• Provides for the timely processing and release of unaccompanied alien children

Care providers are required to evaluate their program’s strengths and weaknesses based on the following performance indicators:

• Number/type of grievances filed by unaccompanied alien children and staff
• Adverse state and local licensing citations
• Allegations and findings of staff misconduct
• On-site accidents
• The use of restraints
• Timeliness of service delivery and discharges for unaccompanied alien children
• Activities related to corrective action plans, if applicable

Posted 6/15/15

5.6 Reporting and Record Keeping

ORR funded care providers submit quarterly and annual performance and financial status reports, and comply with other measures to ensure program integrity and accountability.

If a care provider submits a report that requires revising, the provider must submit a revised report by the indicated due date. Failure to do so may result in immediate issuance of corrective action or other enforcement action.

Posted 7/27/15

5.6.1 Program Reporting Requirements⁵

 
Posted 7/27/15

5.6.2 Maintaining Case Files

Care providers must maintain comprehensive, accurate, and up-to-date case files as well as electronic records on children that are kept confidential and secure at all times and must be accessible to ORR upon request. (Electronic records include those on the care provider’s network drive as well as those on ORR’s case management system.) Care providers must have written policies and procedures for organizing and maintaining the content of active and closed case files that incorporate State licensing requirements and/or accrediting agency requirements, and ORR policies and procedures.

To ensure accurate recordkeeping and the provision of quality care to children, care providers must create an individual case file for each child or youth in its care which includes the child’s name, A-number, date of services, and Federal fiscal year. The file documents all services provided, information about the child or youth’s progress, barriers to the child’s progress, and the outcome of the case.

Each child’s case file must, minimally, include the following:

UC Information

• Name and A Number
• Birth certificate
• Photograph

Placement Documents

• Placement Authorization
• Intakes Placement Checklist
• Inventory of property and cash (signed by child)
• List of clothing and supplies distributed to child
• Notice of Placement in a Restrictive Setting (if applicable)
• Acknowledgment by the child that they have received the orientation in their language regarding program rules and policies; notification regarding self-disclosures made while in ORR custody; grievance procedures; information on boundaries; abuse and neglect; and emergency and evacuation procedures
• Acknowledgment by the child that they have received information regarding the local and/or national service providers and organizations (local child advocacy centers, rape crisis centers, immigrant victim service providers, and/or other community service providers to provide services to victims of sexual abuse and sexual harassment that occurred at the care provider facility) available to assist children

Legal Information

• Acknowledgment of receiving Legal Resource Guide at admission and discharge
• Executive Office of Immigration Review (i.e., immigration court) documents, including those from Flores bond hearings
• Court documents/criminal history records (if applicable)
• Authorization for Release of Records (if applicable)

Medical Records

• Authorization for Medical, Dental, and Mental Health Care
• Documentation of Initial Medical Exam
• Copies of referrals for medical services
• Medical and mental health records (including over-the-counter medications), diagnosis, and documentation of communicable diseases
• Lab results and imaging studies, including CT scans, X-rays, and MRIs
• Immunization Records
• Prescriptions (including prescription logs)
• Record of dental exam(s)
• TB Screening results
• Records of office visits/ER visits/hospital, surgery
• Progress notes related to medical or mental health services (if applicable)
• Diagnosis list

Educational Services

• Summary of educational assessments
• Individualized Education Program (IEP), if applicable.
• Education plan (class placement, curriculum/course descriptions, and records (academic reports, progress notes))

Case Management Records

• Case manager progress notes
• Recreation/activity log
• Telephone log
• Religious services log
• Stipend log (if stipends are mandated by State licensing)
• Individual Service Plan (ISP) and updates
• Sponsor Assessment
• Family Reunification Packet
• Home Study Report 

Clinical/Mental Health Records

• Progress notes from individual counseling sessions
• Group counseling notes or records
• Mental health services progress notes (if applicable)
• Mental health assessments (if applicable)
• Records of mental health office visits, telepsychology/psychiatry/psychotherapy sessions, or hospitalizations (if applicable)
• Psychotropic prescriptions, including prescription logs (if applicable)
• Initial Intakes Assessment
• Assessment for Risk
• UC Assessment
• UC Case Review and updates
• Disclosure Notice for counseling services
• Behavioral Notes (if applicable)
• Historical Disclosures (if applicable).

Incident Reports

• Significant Incident Reports (if applicable)
• Documentation of the facility’s Internal Incidents or reports
• Grievances/Grievance Reports

Discharge/Exit Information

• Verification of Release form
• Transfer Request and Tracking form
• For transfers only, Notice of Transfer to ICE Chief Counsel (Change of Address/Change of Venue)
• Log/checklist including all documents provided to the child at discharge
• Log of property returned/disbursed at discharge
• Discharge checklist for medical records
• Copy of Order of Removal (if applicable) (also see Legal Information above)
• Copy of Trafficking Eligibility Letter (if applicable)

In preparing and managing case files and documentation, the care provider must ensure compliance with all requirements imposed by Federal statutes concerning the collection and maintenance of data that includes personal identifying information.

Revised 08/02/23

5.6.3 Record Management, Retention and Safekeeping

Care providers must ensure that all records are maintained and protected so that confidential information and data are secure and not accessed, used, or disclosed to unauthorized parties or improperly altered.  There must be established administrative and physical controls to prevent unauthorized access to both electronic and paper records. Electronic records, including those in UC Portal, cannot be accessed outside of the United States by any entity within or outside of ORR⁶. The care providers’ internal policies must be consistent with ORR’s policy not to utilize UC Portal outside of the United States. The care provider’s policies and procedures must also address preventing the physical damage or destruction of records.  For sensitive unaccompanied child’s information pertaining to sexual abuse or clinical records, care providers must implement appropriate controls on the dissemination of such information in order to ensure that sensitive information is not exploited to the unaccompanied child’s detriment by staff or other children or youth.

Care providers are also responsible for the timely entry of all required information into the UC Portal. For specific timeframes related to assessment of unaccompanied children and potential sponsors, reporting, and release see:

Section 2.2.3 The Application for Release
Section 3.3.1 UC Assessment and Case Review
Section 3.4.2 Initial Medical Exam
Section 3.4.5 Responding to Medical Emergencies
Section 4.8.1 Assessment for Risk
Section 2.8.2 Transfer of Physical Custody
Section 2.8.3 Closing the Case File

Care providers must provide timely and unrestricted access of all files to ORR or an individual or entity that ORR designates to have access.

Care providers must establish an internal file review system to periodically (once per quarter, at the minimum) review individual case files for completeness and accuracy.

ORR will determine prior to the end of the grant or contract with the care provider how the care provider will handle the retention or disposition of case files and program information created during the period of the agreement. Case files must be stored for the period specified in State licensing standards or its accrediting agency or three years (five for records kept in the UC Portal) from the date the unaccompanied child was released, whichever is longer. (Cases involving litigation must be maintained until the case is resolved.)

Complete closed case files may be scanned and saved electronically, if State licensing regulations permit. The care provider must state in its internal policies and procedures the length of time the care provider will retain records in compliance with ORR requirements, State licensing regulations, and/or the accrediting agency requirements.

Once the term for records retention matures, the care provider must inform ORR and seek guidance on how to dispose of or transfer the records.  Care providers may never destroy, keep, or transfer records without prior authorization from ORR.

Active and closed case files must be maintained in a locked file cabinet when not in use. At the minimum, care providers must ensure:

• Records, both paper or electronic, are protected from public access
• The area where paper records or electronic storage equipment is stored is supervised and/or securely locked during business hours to prevent unauthorized persons from accessing the records
• Records are inaccessible to unauthorized persons
• Records are not shared with unauthorized persons or under unauthorized circumstances in either oral or written form
• Safeguards are in place to prevent the misuse of documents
• All care provider sub-contractors, consultants, and outside parties are prohibited from using or disclosing information regarding the program for any purpose other than those detailed in the governing contract or agreement
• Sub-contractors or consultants return all ORR documents or destroy non-ORR documents at the completion of the contract
• ORR consent is obtained prior to destroying any documentation (disposable documents must be properly disposed of by shredding or by hiring a reputable company to take care of proper disposal)

Posted 2/27/23

5.7 ORR Policies to Protect Sponsors from Fraud

ORR does not charge any fee to prospective or approved sponsors as a condition of release of an unaccompanied alien child. Any demand for payment of fees is not authorized by ORR and should not be paid.

Prospective sponsors should immediately report any suspicious calls or requests for payment to the care provider facility, ORR directly, or the ORR National Call Center Help Line at 1 (800) 203-7001.

Posted 7/27/15

5.7.1 ORR Efforts to Help Prevent Fraud

Care providers notify all potential sponsors that ORR, its care providers, volunteer agencies, and grantees/contractors do not collect or require fees for any services related to the release of unaccompanied alien children from HHS custody.⁷

In order to detect potential fraud schemes, ORR also asks all approved sponsors at the time of a child’s release if they have been approached by anyone asking for money at any point in the release process.

The FBI recommends that all members of the public should exercise caution and adhere to the following guidelines before making a payment or donation of any kind:

• Be skeptical of individuals representing themselves as officials and asking for payments or donations door-to-door, via phone, mail, e-mail, or social networking sites.
• Be skeptical of individuals requesting payment or contributions by courier or wire, or those who request your bank account or credit card number.
• Verify the legitimacy of the government agency or non-profit organization by utilizing various Internet-based resources which may confirm the correct phone number, e-mail, and/or the group’s existence and its non-profit status rather than following a link to an e-mailed site.
• Call the official telephone number of the government agency seeking money to ensure the request for payment is legitimate.
• Do not respond to any unsolicited (spam) incoming e-mails. Do not click links contained within those messages.
• Be cautious of e-mails that claim to show pictures of intended recipients in attached files which may contain viruses. Only open attachments from known senders.
• Make contributions directly to known organizations rather than having others make the donation on your behalf to ensure contributions are received and used for intended purposes.
• Do not give your personal or financial information to anyone who seeks payment or solicits contributions. Providing such information may compromise your identity and make you vulnerable to identity theft.

See www.fbi.gov/sanantonio/press-releases/2014/new-fraud-schemes-targetin... for the Spanish translation of this warning.

ORR also requests that sponsors:

• Report any suspicious calls or contact to the care provider facility and ORR directly.
• Call the ORR National Call Center Help Line at 1 (800) 203-7001. Sponsors may call the help line to inform ORR if a person defrauds or attempts to defraud them of money.

Posted 7/27/15

5.7.2 Responding to Fraud Attempts

If a care provider determines that a sponsor or prospective sponsor has been the target of a fraud attempt, the care provider must report the incident to ORR through a Significant Incident Report (SIR) and to local law enforcement.

ORR reviews the information in the SIR and reports all fraud schemes, whether attempted or successfully perpetrated, to HHS/Office of the Inspector General (OIG). ORR and the care provider may provide ongoing consultation to HHS/OIG on their investigation, including providing circumstantial information surrounding the fraud scheme and additional clarification of facts after submitting the SIR. To obtain case file records pertaining to such an  investigation, HHS/OIG must file a case file records request using the Authorization for Release of Records form following the process outlined in Section 5.10.1 UC Case File Request Process. Requests may be expedited at ORR’s discretion subject to the criteria in Section 5.10.1 UC Case File Request Process.

If the fraud scheme involves care provider staff, ORR instructs the care provider to contact local law enforcement and to follow their local licensing guidelines regarding reports of inappropriate employee behavior and to inform their local licensing agency that the case was referred to HHS/OIG and local law enforcement. A care provider facility must take disciplinary action including termination of any staff for criminal behavior, including fraud. ORR issues corrective action findings and requires the care provider to take appropriate action.  See Section 5.5.2 Follow Up and Corrective Actions.

Revised 08/07/2023

5.8 Reporting Child-Level and Program-Level Events

ORR requires that care providers and ORR staff report incidents affecting an unaccompanied child’s (UC) safety and well-being and record observations that can inform how best to meet their needs. Care providers must report on a wide range of incidents and observations, including but not limited to abuse/neglect by staff, destruction of property by children, mental health concerns, and natural disasters that affect a program’s functioning. Below is a chart that illustrates the broad types of events that care providers report to ORR:

Reporting these events to ORR helps ensure that significant incidents involving children are documented and responded to in a way that protects the best interests of children in ORR care, including their safety and well-being. Incident reports are not a complete or comprehensive record of a child’s time in care because they are primarily meant as internal records whose purpose is to document and communicate incidents for ORR’s immediate awareness (and not, for example, as legal documents, medical or clinical records, or as dispositive decision documents regarding aspects of a child’s case management needs). Unless otherwise stated, information may not be fully verified; the incident itself or actions to address the incident may be ongoing and require several addendums.  Further, an incident report is not intended to provide a complete context (such as trauma, other incidents) of the incident described or of the child’s experience in home country, journey, or time in care.    

Under no circumstances may care providers threaten children with incident or event reporting to regulate their behavior or for any other reason.

Section 5.8 describes each category of event and its reporting requirements; contains reference charts for reporting; and includes instructions for notifying certain non-governmental stakeholders (e.g., attorneys, potential sponsors, etc.).

Some events will rise to the level of an emergency and require prompt notification to ORR, in addition to the timely completion of an official Emergency Significant Incident Report (SIR) form. See Section 5.8.1 Emergency Incidents for reporting and notification requirements.

In other non-emergency cases, care providers are required to report significant incidents to ORR using an official SIR form through the ORR case management system. See Section 5.8.2 Significant Incidents for reporting and notification requirements.

Broadly, child-level events (CLE) are incidents, events, and observations that affect individual children and include emergency incidents, significant incidents, behavioral notes, and historical disclosures. Emergency incidents and significant incidents follow reporting requirements in Section 5.8.1 Emergency Incidents and Section 5.8.2. Significant Incidents respectively, while behavioral notes and historical disclosures follow reporting requirements in Section 5.8.12 Behavioral Notes and Historical Disclosures. Conversely, some events, referred to as “program-level events” (PLE) may affect the entire care provider facility and/or children and staff within (e.g., an active shooter or natural disaster). Care providers are required to report these events to ORR using an official PLE Report form through the ORR case management system. See Section 5.8.3 Program-Level Events for reporting and notification requirements.

Care providers must ensure that each report includes sufficient detail regarding the incident or event to accurately describe it in a sequential manner, identifies the individuals involved, avoids judgmental or disparaging language about children, and records all follow-up actions. Properly documenting incidents helps identify dangers and avoid situations that could potentially endanger children and staff. When emergencies, significant incidents, or PLEs occur, ORR staff and care providers must prioritize the safety of children and staff ahead of reporting requirements. See Section 5.5 ORR Monitoring and Compliance and Section 4.6 Coordinated Response for further information about ORR’s standards for monitoring and compliance, including actions ORR may take to ensure the safety and well-being of children in its care.

These reports may not be provided to any outside entity or individual without prior permission from ORR, unless stated otherwise in ORR policies and procedures. Any notification emails sent to external entities about relevant incidents (such as those subject to mandatory reporting in accordance with state, local, or federal law or ORR policy) must include the SIR Triage Team at [email protected]. 

Revised 08/02/23

5.8.1 Emergency Incidents

Emergency incidents include (1) urgent situations in which there is an immediate and severe threat to a child’s safety and well-being that requires immediate action, or (2) unauthorized absences.

Emergency incidents include, but are not limited to:

• Abuse or neglect in ORR care where there is an immediate and severe threat to the child’s safety and well-being, such as physical assault resulting in serious injury, sexual abuse, or suicide attempt;
• Death of a child in ORR custody, including out-of-network facilities (see Section 3.3.16 Notification and Reporting of the Death of an Unaccompanied Child);
• Medical emergencies, as defined in Section 3.4.5 Responding to Medical Emergencies;
• Mental health emergencies requiring hospitalization; and
• Unauthorized absences of children in ORR custody (see Section 5.8.8 Reporting SIRs to DHS for additional reporting requirements). 

Reporting:

Care providers must immediately report emergency incidents, as appropriate, to 9-1-1, local law enforcement, Child Protective Services (CPS), HHS Office of the Inspector General, and the State licensing agency, in accordance with mandatory reporting laws, State licensing requirements, Federal laws and regulations, and ORR policies and procedures. Care provider facilities also must immediately report emergencies to the ORR Federal Field Specialist (FFS) Supervisor overseeing that facility. For unauthorized absences, care providers must automatically notify the LSP or attorney of record (if applicable), as well as the appointed Child Advocate if there is one, within 48 hours.

Care providers must submit an Emergency SIR in ORR’s case management system within four hours of an emergency incident (or within four hours of the care provider becoming aware of the incident). An Emergency SIR must be filed for each child involved in an emergency incident, and multiple Emergency SIR Addendums may be required to provide all updated and additional information after the initial Emergency SIR is submitted (see Section 5.8.4 Report Addendums).

Any notification emails to entities outside of ORR must include the SIR Triage Team at [email protected]. 

5.8.2 Significant Incidents

Significant incidents are (1) situations that may immediately affect the safety and well-being of an unaccompanied child or (2) observations that may affect how a care provider can best meet a child’s needs while in care. 

Significant incidents include, but are not limited to:  

• Abuse or neglect of an unaccompanied child by an adult while in(ORR) care; 
• Sexual harassment or inappropriate sexual behavior; 
• Staff code of conduct and boundary violations; 
• External threats to children, such as: 
  • Outside actors perpetrating actual or potential fraud schemes on children or their sponsors; 
  • Human trafficking concerns or risks; and 
  • Threats to a child while in ORR care related to crime or organized crime  
• Incidents involving law enforcement on-site at the care provider; 
• Outside actors perpetrating potential fraud schemes on children or their sponsors; 
• Incidents of intentional document or information fraud, such as; 
  • An unaccompanied child, or an adult acting as an unaccompanied child, who misrepresents their identity or age; 
  • An adult who misrepresents their biological or familial relationship to an unaccompanied child;  
  • A sponsor or potential sponsor who misrepresents their identity or identity documentation; 
  • A sponsor or potential sponsor who misrepresents the whereabouts or welfare of other children, including former unaccompanied children in the household; 
  • A sponsor or potential sponsor who misrepresents information submitted in connection with a sponsor application, sponsor assessment, and/or supporting documentation; 
  • A sponsor or potential sponsor who incorrectly reports an address, current work status, or intended care plans of a child.  
• Healthcare errors; 
• Requests for termination of pregnancy; 
• Runaway attempts; 
• Mental health concerns; and 
• Use of behavioral safety measures, such as restraints. 

Reporting: 
Care providers must submit a completed SIR in ORR’s case management system within 24 hours of the significant incident (or within 24 hours of the care provider becoming aware of the incident).  

Care providers also must report significant incidents, as appropriate, to Child Protective Services (CPS), State licensing, and/or local law enforcement, in accordance with mandatory reporting laws, State licensing requirements, Federal laws and regulations, and ORR policies and procedures. 

NOTE: ORR’s Integrity and Accountability Team (I & A) will report all fraud related incidents to HHS OIG. Care providers and field staff should not report fraud related incidents to HHS OIG, however, staff must respond if HHS OIG requests additional circumstantial information or clarification of facts (see Policy Guide Section 5.7.2) or utilize the case file request process to obtain records related to an investigation (see Policy Guide Section 5.10.7).  

Additionally, some SIRs require notification to Department of Homeland Security (DHS). See Section 5.8.8 Reporting SIRs to DHS. 

An SIR must be filed for each child involved in a significant incident, and multiple SIR Addendums may be required to provide all updated and additional information after the initial SIR is submitted (see Section 5.8.4 Report Addendums). A copy of each SIR and SIR Addendum must be kept in the child’s case file. 

Any notification emails to entities outside of ORR must include the SIR Triage Team at [email protected]. 

Revised 02/09/24 

5.8.3 Program-Level Events

Program-level events (PLE) are situations that affect the entire care provider facility and/or children and staff within and require immediate action. 

PLEs include, but are not limited to: 

• Death of a staff member, other adult, or non-UC child at a care provider facility or foster home; 
• Major disturbance (e.g., shooting/terrorist attack, riot, protest, etc.); 
• Natural disaster (e.g., earthquake, flood, tornado, wildfire, hurricane, etc.); and  
• Any event that affects normal operations for the care provider facility (e.g., long-term power outage, gas leaks, inoperable fire alarm system, infectious disease outbreak,8 stoppage of intakes/discharges that affects the entire facility, any safety or abuse/neglect concern where the child has not yet been identified, etc.). 

Reporting: 
Care providers must immediately report PLEs, as appropriate, to 9-1-1, local law enforcement, CPS, and/or State licensing, in accordance with mandatory reporting laws, State licensing requirements, Federal laws and regulations, and ORR policies and procedures. Care provider facilities must also immediately report PLEs to the ORR FFS Supervisor. 

Care providers must submit a PLE Report  in the ORR case management system within four hours of the event (or within four hours of the care provider becoming aware of the event)—or as soon as practicable. For PLEs that occur over multiple days, or if the situation changes, follow-up reporting may be required. Care providers are required to submit a final PLE Report after the incident is resolved. 

If children are injured or become ill as a result of the PLE, and the injury or illness rises to the level of a medical emergency (as defined in Section 3.4.5 Responding to Medical Emergencies), an SIR must be filed for each injured or ill child as outlined in Section 5.8.1 Emergency Incidents. 

Any notification emails to entities outside of ORR must include the SIR Triage Team at [email protected]. 

Revised 08/02/23

5.8.4 Report Addendums

Care providers must create an addendum to an existing Emergency SIR and SIR when information in the original document was incorrect or incomplete or new information becomes available about the incident. Care providers should update the PLE in the original report when information in the original document was incorrect or incomplete or new information becomes available about the incident. Examples of information that care providers should document in addendums include a discussion with the potential sponsor about the incident; media inquiries; and receipt of official reports from State or local government agencies. 

Care providers must submit addendums to SIRs or updates to PLEs to ORR within 24 hours of learning of the incorrect, incomplete, or new information.

Revised 6/7/21

5.8.5 Elevation of Emergencies, Significant Incidents, and Program-Level Events

ORR elevates certain emergencies and significant incidents within its leadership structure as an additional measure of protection to help ensure children are safe and receive appropriate care, and to provide care providers and ORR field staff the support needed in handling the most difficult and sensitive situations. 

In the following cases, the Federal Field Specialist (FFS) receiving the report must immediately elevate the case to their FFS Supervisor and SIR Triage Team ([email protected]) simultaneously, and the SIR Triage Team then elevates the case (while keeping the relevant FFS and FFS Supervisor in the email) to the Field Manager, the Director of the Division of Unaccompanied Children Operations (DUCO), the Director of the Division of Policy and Procedures (DPP), Associate UC Program Director, Manager of Project Officers and Grants Management, ORR Chief of Staff, Director of Division of Planning and Logistics (DPL) (as applicable), Division of Health for Unaccompanied Children (DHUC) (as applicable), and the ORR Director.  

• Death of a child, staff, or other person in a care provider facility or foster home; 
• Situations in which the lives of children or care provider staff are in immediate danger (e.g., shooting/terrorist attack, natural disaster, medical emergency — as defined in Section 3.4.5 Responding to Medical Emergencies, mental health emergency requiring hospitalization, and/or potential infectious disease outbreak);  
• Unauthorized absences of children in ORR custody; and 
• Any situation that is reasonably likely to require ORR leadership oversight or escalation to the leadership of the Administration for Children and Families and/or U.S. Department of Health and Human Services. 

In cases that affect the entire care provider facility, such as a shooting/terrorist attack or natural disaster, the SIR Triage Team  will elevate the case to the Director of DPL. 

In cases of a death of a child, a medical emergency, or a mental health emergency requiring hospitalization of a child, the SIR Triage Team will elevate the case to the Director of DHUC. 

In cases of a potential infectious disease outbreak, ORR staff receiving the report shall immediately elevate the case to their immediate supervisor, who in turn elevates the case to DHUC. DHUC reviews the case and elevates any confirmed outbreaks simultaneously to the Field Manager, Manager of Grants and Project Management, the Director of DPL, Director of DUCO, , Associate UC Program Director, Director of DPP, ORR Chief of Staff, and the ORR Director. 

QUICK REFERENCE CHART: ORR Supervisor Requirements for Elevation of Emergencies, Significant Incidents, and Program-Level Events 

NOTE: The chart is intended as a quick reference guide and does not cover every type of reportable incident. 

Revised 08/02/23

5.8.6 Allegations of Sexual Abuse in ORR Care

ORR has a zero-tolerance policy for all forms of sexual abuse, sexual harassment, inappropriate sexual behavior, and staff code of conduct violations at care provider facilities and foster family homes and makes every effort to prevent, detect, and respond to such conduct. For detailed information on reporting allegations of sexual abuse, sexual harassment, inappropriate sexual behavior, and staff code of conduct violations, see Section 4.10 Reporting and Follow-up.

Revised 6/7/21

5.8.7 Allegations of Child Abuse in DHS Custody

If a child makes an allegation of child abuse, including sexual abuse, sexual harassment or inappropriate sexual behavior, that occurred while he or she was in DHS custody, care providers must report the allegation according to State mandatory reporting laws and ORR policies and procedures. See definitions for physical abuse, verbal/emotional abuse, neglect, and medical neglect in the Guide to Terms.

Care providers must document the allegation as a Historical Disclosure (Section 5.8.12 Behavioral Notes and Historical Disclosures) in ORR’s case management system within 24 hours.. ORR then reports these allegations of abuse to DHS Customs and Border Protection and DHS Office for Civil Rights and Civil Liberties.  

Revised 6/7/21

5.8.8 Reporting SIRs and Historical Disclosures to DHS

The following chart outlines care provider reporting requirements for significant incidents and historical disclosures that must be reported to DHS.

Care providers must not include clinical or mental health information in SIRs or historical disclosures that are reported to DHS unless required by mandatory reporting laws.

QUICK REFERENCE CHART: Care Provider Reporting Requirements for Significant Incidents and Historical Disclosures to DHS

NOTE: The chart is intended as a quick reference guide and does not cover every type of reportable incident or disclosure.

* Where notification occurs via email. If the entity to which the care provider is reporting an event requires notification via their own website or portal, care providers should also upload a copy of that completed form into ORR’s case management system as an addendum in the relevant SIR. 
 

The following chart outlines FFS reporting requirements for significant incidents that must be reported to DHS. 

QUICK REFERENCE CHART: FFS Reporting Requirements for Significant Incidents to DHS 

NOTE: The chart is intended as a quick reference guide and does not cover every type of reportable incident. 

Revised 08/02/23

5.8.9 Allegations of Past Abuse that Occurred Outside of the United States

If a child or youth reports past abuse that occurred in his or her home country or on the way to the United States, care providers must document it as a Historical Disclosure (Section 5.8.12 Behavioral Notes and Historical Disclosures) and follow State licensing requirements, as applicable, to report the allegations of abuse. Any notification emails to entities outside of ORR must include the SIR Triage Team at [email protected] for the team to track incidents and reporting compliance.

Revised 08/02/23

5.8.10 Allegations of Past Abuse that Occurred Inside of the United States

All allegations of abuse that occurred within the United States (but not when the child was in the custody of the Federal government) must be reported to the care provider’s State licensing agency, CPS, and local law enforcement, in accordance with State licensing requirements, as applicable, and must be documented as a Historical Disclosure (Section 5.8.12 Behavioral Notes and Historical Disclosures). For allegations of sexual abuse in the United States, care providers must also elevate the case to the ORR Prevention of Sexual Abuse Coordinator at [email protected].

If the State licensing or CPS agency directly reports an allegation to local law enforcement, the care provider does not need to make a separate report but must confirm and document when such a report has been made. Care providers must report allegations of abuse involving an adult to local law enforcement, regardless of whether State licensing or CPS reports the allegation. Any notification emails to entities outside of ORR must include the SIR Triage Team at [email protected] for the team to track incidents and reporting compliance.

Revised 08/02/23

5.8.11 Notification to Attorneys, Legal Representatives, Child Advocates, Families, and Sponsors

Care providers must notify, as appropriate, attorneys of record, legal service providers, child advocates, parents or legal guardians, and potential sponsors certain types of SIRs.

Referrals/Notifications to Legal Service Providers (LSPs) and Attorneys of Record  

Care providers MUST automatically refer children to the on-site legal service provider (LSP) (or notify the child’s attorney of record, if applicable) for a follow-up legal screening in the following events: 

• A child is reported to be involved in the following Emergency SIRs: 
  • Incidents Involving Weapons 
  • Severe Abuse/Neglect 
• A child is reported to be involved in the following SIRs: 
  • External Threats to UC 
  • Incidents Involving Law Enforcement On-Site 

Also see Section 4.10.4 Notification and Access to Attorneys/Legal Representatives, Families, Child Advocates, and Sponsors and Section 5.8.12 Behavioral Notes and Historical Disclosures for additional circumstances that require a referral the LSP or attorney of record. 

The care provider must explain to the child that they are being automatically referred to an attorney who can assess whether the incident will affect the child’s immigration case. The referral must take place within 48 hours of the care provider becoming aware of the SIR requiring triggering a referral.  

If the child is 14 years or older: The care provider must not disclose the type of SIR or Emergency SIR (or related information) requiring the referral to the LSP or attorney of record.

If the child is 13 years or younger, or has a diagnosed developmental disability at any age: The care provider must automatically disclose the type of SIR or Emergency SIR requiring the referral (but not the SIR itself) in the email referral to the LSP or attorney of record. 

The care provider must not provide a copy of the underlying SIR (or related information) for the follow-up legal screening until/unless the LSP or attorney of record completes the Authorization for Release of Records in accordance with Section 5.10.1 UC Case File Request Process. 

If a care provider reports an Unauthorized Absence for an unaccompanied child, the care provider must also automatically notify the LSP or attorney of record (if applicable) within 48 hours. 

Referrals to the Child Advocate 

Care providers MUST automatically refer children to the Child Advocate in the following circumstances: 

• A child is reported to be involved in the following Emergency SIRs:
  • Severe Abuse/Neglect
• A care provider documents one of the following types of SIRs: 
  • Incidents Involving Law Enforcement On-Site
  • External Threats to UC
    1. Labor trafficking concern or risk identified
    2. Sex trafficking concern or risk identified 

The care provider must make clear to the child that they are being automatically referred to a Child Advocate (if the child does not already have one appointed), who, if appointed, will provide recommendations in the child’s best interests regarding the child’s care or placement. The referral must take place within 48 hours of the care provider becoming aware of the triggering SIR.

Care providers must use the Child Advocate Recommendation and Appointment Form available on ORR’s case management system to make the referral.

Only if/when the Child Advocate confirms that they are appointed to the child’s case and has sent ORR the completed Child Advocate Recommendation and Appointment Form may the care provider furnish the Child Advocate with the child’s complete case file, including SIR documentation. 

If a care provider reports an Unauthorized Absence for an unaccompanied child, the care provider must automatically notify the child’s appointed Child Advocate (if there is one) within 48 hours.

For any child who is hospitalized or requires a serious medical service, care providers must notify the child’s child advocate (if applicable), parent or legal guardian and sponsor, in accordance with Section 4.10.4 Notification and Access to Attorneys/Legal Representatives, Families, Child Advocates, and Sponsors and Figure 4.10.2. 

More information on the role of Child Advocates can be found in Section 2.3.4 Child Advocates. 

Arrests

Care providers should make every effort to de-escalate a conflict to prevent the need to contact law enforcement (see Section 3.3.13 Behavior Management). 

If a child is arrested by law enforcement, care providers should—within four (4) hours of the arrest during regular business hours or the morning of the next calendar day—complete the following notifications to:

• the child’s parent or legal guardian, if possible and if there are no specified child welfare reasons not to provide notice;
• the LSP or attorney of record (if applicable);
• the appointed Child Advocate (if applicable); and
• any potential sponsor, if possible and if there are no specified child welfare reasons to not provide notice

When making notifications to the individuals listed above, care providers shall also specify the following information:

• that the child was arrested, but:
  • If the child is 14 years or older: the care provider must not disclose details about the arrest unless child consents to disclosing those details
  • If the child is 13 years or younger or has a diagnosed developmental disability at any age:  the care provider must automatically disclose the details of the arrest if known;
• the child’s present location, if known;
• a law enforcement point of contact; and
• a public defender point of contact, if known.

Care providers shall make reasonable and timely efforts to notify law enforcement of information necessary to ensure the child’s immediate safety while in law enforcement custody, such as current medications or allergies, any disability-related accommodation needs (e.g., the need for hearing aids), or whether the child is at documented enhanced risk for suicide.

ORR will begin planning for the child’s return to ORR custody within one (1) calendar day of the child’s arrest to ensure there is an appropriate ORR placement available for the child upon their release and minimize the time, if any, that the child spends waiting for an ORR placement following release from law enforcement. 

Notification and Access to Families and Sponsors

Care providers must notify, as appropriate, parents or legal guardians, and potential sponsors of any type of abuse and neglect, incidents involving law enforcement on-site, and unauthorized absences. Care provider facilities must ensure children have access to their families, including legal guardians, unless ORR has documentation that certain family members or legal guardians should not be provided access due to safety concerns. Care providers must provide a notification only and may not send SIRs.  

If a child is arrested by law enforcement, care providers should—within four (4) hours of the arrest during regular business hours or the morning of the next calendar day—notify the child’s  parent, legal guardian, and/or sponsor, if possible, and if there are no specified child welfare reasons not to provide such notice.

QUICK REFERENCE CHART: Notification to Parents/Legal Guardians and Sponsors here

Care providers must document any and all notifications made in ORR’s case management system.

Revised 08/02/23

5.8.12 Behavioral Notes and Historical Disclosures

Behavioral Notes

In some instances, it may be beneficial for care providers to document behaviors or observations about children that highlight positive events or developments in the children's daily life while in care. Examples include demonstrating significant improvement in developing life skills or doing particularly well in a class, program, or activity. It may also be beneficial for care providers to document patterns of behavior that potentially merit intervention or support over time. Examples include benign, developmentally appropriate horseplay or adolescent non-compliance with staff instructions. Such observations may be documented as a Behavioral Note in the child’s ORR’s case management system where it could be helpful to have a record of the behavior for the purpose of adding meaningful context for the child’s time in ORR care and to provide support and/or relevant services that meet the child’s individual needs. Documenting behavioral notes is optional and at the care provider’s discretion on whether a given observation is worth documenting.

Under no circumstances may care providers threaten children with the use of Behavioral Notes to regulate their behavior or for any other reason.

Behavioral Notes are subject to the information sharing prohibitions described in Section 5.10.2, Limits to Sharing Information with DHS and EOIR (i.e., ORR prohibits the sharing of non-essential case information with DHS and EOIR, which includes behavioral reports). Further, ORR will not release any records to a government agency if the records request is clearly outside the scope of the agency’s authority or if the request appears to be for immigration enforcement purposes (even in cases where an authorizing signature is provided) absent a lawfully issued subpoena or court order (see Section 5.10.1 UC Case File Request Process). Behavioral Notes are also subject to information sharing prohibitions described in Section 5.9.2 Protecting Confidentiality of Mental Health and Medical Records, when applicable, as well as the Disclosure Notice Requirements in Section 5.9.1 Requirement to Inform Children of Limits to Confidentiality.

Historical Disclosures

Incidents that have occurred prior to the child coming into ORR care and custody should be documented as a Historical Disclosure in ORR’s case management system within 24 hours of disclosure from the child. Examples of past incidents that should be captured as a Historical Disclosure include abuse/neglect in DHS custody, abuse/neglect allegations that occurred in the United States but not while in federal custody, or other abuse or traumatic events in home country. The purpose of the Historical Disclosures is to document past incidents of abuse, neglect, other harm, or threats of harm that occurred before the child came into ORR care that may inform how a care provider can best meet a child’s needs, such as by providing relevant mental health support. Additionally, this documentation helps ensure that relevant investigative entities are notified of threats like human trafficking. It is the care provider’s responsibility to render any relevant support services in response to a historical disclosure (such as mental health support following disclosure of a past traumatic event).

Reporting Requirements

Care providers must report past abuse or neglect that occurred in home country, during the child’s journey, or otherwise in the United States prior to coming into ORR care and custody, as appropriate, to relevant state child protective service entities, State licensing, and/or law enforcement, in accordance with mandatory reporting laws, State licensing requirements, Federal laws and regulations, and ORR policies and procedures within 24 hours of the disclosure.  

Care providers must also report certain disclosures to various other stakeholders, as outlined below.

Also see Section 4.10.4 Notification and Access to Attorneys/Legal Representatives, Families, Child Advocates, and Sponsors and Section 5.8.11 Notification to Attorneys, Legal Representatives, Child Advocates, Families, and Sponsors for additional circumstances that require a referral the LSP and/or Child Advocate.

Referrals/Notifications to LSPs and Attorneys of Record

Care providers must automatically refer children to the legal service provider (LSP) (or notify the child’s attorney of record, if applicable) for a follow-up legal screening within 48 hours if one of the following types of Historical Disclosures is reported:

• Abuse/Neglect in DHS Custody;
• Past Abuse/Neglect Not in ORR Care or DHS Custody;
• Self-Disclosed Juvenile Delinquency.

The care provider must explain to the child that they are being automatically referred to an attorney so that the lawyer can assess whether the disclosure will affect their immigration case.

If the child is 14 years or older: The care provider must not disclose the type of historical disclosure requiring the referral to the LSP or attorney of record.

If the child is 13 years or younger, or has a developmental disability at any age: The care provider must automatically disclose the type of historical disclosure requiring the referral (but not the Historical Disclosure itself) in the email referral to the LSP or attorney of record.

The care provider must not provide a copy of the Historical Disclosure for the follow-up legal screening until/unless the LSP or attorney of record completes the Authorization for Release of Records in accordance with Section 5.10.1 UC Case File Request Process.

Referrals to a Child Advocate

Care providers must automatically refer children to a Child Advocate within 48 hours if one of the following types of Historical Disclosures is reported:

• Labor Trafficking
• Sex Trafficking

The care provider must make clear to the child that they are being automatically referred to a Child Advocate (if the child does not already have one appointed), who, if appointed, will provide recommendations in the child’s best interests regarding the child’s care or placement.

Care providers must use the Child Advocate Recommendation and Appointment PDF Form available on ORR’s case management system to make the referral. The care provider may provide basic information about the reason for the referral in the form.

Only if/when the Child Advocate confirms that they are appointed to the child’s case may the care provider furnish the Child Advocate with the child’s complete case file, including SIR or Historical Disclosure documentation.

More information on the role of Child Advocates can be found in Section 2.3.4 Child Advocates.

Reporting Sexual Abuse and Sexual Harassment that Occurred in DHS Custody

For allegations of sexual abuse, sexual harassment, and inappropriate sexual behavior occurring in DHS custody, care providers must follow reporting requirements in Section 5.8.8 Reporting SIRs and Historical Disclosures to DHS and must remember to make report within 24 hours. Care providers must report suspicions about the possibility of human trafficking or smuggling to the Office of Trafficking in Persons (OTIP) within 24 hours. Allegations of other sexual abuse, sexual harassment, and inappropriate sexual behavior that occurred outside of ORR care and DHS custody should be reported in accordance with Section 4.10.2 Care Provider Reporting Requirements.

NOTE: only some Historical Disclosure notes are reportable to DHS. Only the disclosures listed in Section 5.8.8 Reporting SIRs and Historical Disclosures to DHS may be shared with DHS. Other disclosures by children that are documented within Historical Disclosures that are not listed in Section 5.8.8 may not be shared with DHS without (1) the child’s consent, and (2) completing the case file request process (see Section 5.10.1 UC Case File Request Process, and any such disclosures to DHS must also be in compliance with Section 5.10.2, Limits to Sharing Information with DHS and EOIR).

For health-related historical disclosures, care providers will also notify ORR’s Division of Health for Unaccompanied Children.

Posted 08/02/23

5.9 Protecting the Privacy and Confidentiality of UC Information

The below sections describe ORR’s internal agency policies and practices on protecting the privacy and confidentiality of children’s information, as well as limits to the confidentiality of certain types of information shared by the child while in ORR care. ORR treats information maintained in ORR systems of records on non-U.S. persons, including case files containing information about UC and sponsors, as being subject to the administrative provisions of the Privacy Act.

UC Program records include all records pertaining to individual unaccompanied children and former unaccompanied children, including all information the care provider or ORR staff has collected regarding unaccompanied children, in both written and electronic forms. This includes but is not limited to all records specified in Section 5.6.2 Maintaining Case Files⁹. All contractors and grantees who support the UC Program must comply with the requirements of the Privacy Act when they access or use Privacy Act-protected records of the Department.

As stated in Section 5.3.3 Prohibition on Release of Records Without Prior Approval, UC Program records are the property of ORR and may not be released without prior approval from ORR in accordance with policies set forth in  the ORR UC Program Policy Guide. UC Program records contain highly sensitive information about program participants and must be kept confidential and protected from unauthorized disclosure for privacy as well as safety reasons¹⁰. However, ORR or HHS may need to provide UC case file information pursuant to a lawsuit or in response to UC program oversight investigations, audits, evaluations, and inspections conducted by the U.S. Department of Health and Human Services’ Office of the Inspector General (OIG); the Government Accountability Office (GAO); or in response to Congressional inquiries (please see and Section 5.10.7 Information Sharing with Investigative Agencies for requirements on investigations involving child safety and individual case files).

The sections below describe ORR’s records privacy and confidentiality policies and practices applicable to UC Program records, as well as procedures for requesting records.

Revised 08/07/2023; Effective 08/21/2023

5.9.1 Requirement to Inform Children of Limits to Confidentiality

ORR ensures that children are informed of the limits to the confidentiality of information they share while in ORR care and custody, as well as the types of information and entities to which such information must be disclosed by the care provider and ORR for the safety of the child or for the safety of others. Care providers are required to verbally explain the Disclosure Notice with each child in their preferred language twice—once prior to the completion of the UC Assessment and again prior to starting clinical sessions as noted in Section 3.2.1 Admissions for Unaccompanied Children. The Disclosure Notice must be reviewed again with the child after each transfer within the ORR care provider network, according to the same timeframe requirements (prior to the completion of the UC Assessment, and again prior to starting clinical sessions).

The Disclosure Notice explains to the child that the majority of the information that a child discloses in counseling or during other assessments remains confidential, but there are certain exceptions to this confidentiality when it is necessary to share this information for the child’s safety or the safety of others, according to mandatory reporting requirements and according to Section 5.8 Reporting Child-Level and Program-Level Events. Additionally, children are informed that mental health information is not released to the U.S. Department of Homeland Security (DHS) without their consent.  

Care providers are required to inform the child of situations where their case file or other records may be shared with entities outside of ORR in limited scenarios (e.g., if required by a federal court subpoena). Care providers must have accountability systems and policies in place to protect the confidentiality of UC information and records from unauthorized use or disclosure in accordance with:

• Section 3.3 Care Provider Required Services
• Section 3.4.7 Maintaining Health Care Records and Confidentiality
• Section 5.3.2 Confidentiality of Information
• Section 4.8.2 Use of Assessment Information
• Section 4.10.5 Confidentiality
• Section 5.3.3 Prohibition on Release of Records Without Prior Approval
• Section 5.6.2 Maintaining Case Files
• Section 5.6.3 Record Management, Retention and Safekeeping
• Section 6.2.5 Post-Release Service Records Management, Retention and Information Sharing
• Section 7.5 Influx Care Facility Required Services

Revised 08/07/2023; Effective 08/21/2023

5.9.2 Protecting Confidentiality of Mental Health and Medical Records

In recognition of the confidential nature of clinical sessions, most information disclosed by children during such sessions while in ORR care, as well as related documentation, including case notes and records of therapists and other clinicians, remains confidential and is only released subject to the policies in this section and Section 5.10 Information Sharing.¹¹ ORR also does not share any clinical or mental health records with any immigration court for master calendar hearings, where the court is not making decisions about the child’s custody (see Section 5.10.2 Limits to Sharing Information with DHS and EOIR).¹²

In cases where ORR would require the child’s consent to share mental or medical health records, but the child in ORR custody is unable to consent due to age, a diagnosed developmental disability, or other medical or mental health condition¹³, ORR generally provides consent when the information is needed for the provision of services in accordance with Section 3.3 Care Provider Required Services.

For confidentiality policies on medical records related to pregnancy, birth, and abortion, please reference the Policy Memorandum: Medical Services Requiring Heightened ORR Involvement (PDF).

If medical or mental health records are requested for reasons other than the provision of services, ORR requires the authorizing signature and consent of the child or the child’s caregiver (parent/legal guardian or sponsor) as specified in Figure 5.10.3 Signature Requirements for Release of Sensitive Information. In cases where the child was released from ORR custody and is unable to consent due to age, diagnosed developmental disability, or other medical or mental health condition, ORR requires the consent of the child’s caregiver (parent/legal guardian or sponsor). If child’s caregiver (parent/legal guardian or sponsor) is unable to provide consent (i.e., child is orphaned, parent/legal guardian cannot be located), ORR may provide consent for the release of medical or mental health records if the request is in the best interest of the child. Additionally, care providers must follow applicable state laws regarding consent for release of medical or mental health records.

If local law enforcement agency or other investigative agencies request medical records through the case file request process in cases where a child has been reported missing from ORR care or after release from ORR care, the records may only be shared if the UC Program Director provides approval.

Revised 08/07/2023; Effective 08/21/2023

Footnotes

1. Emergency Supplemental Appropriations for Humanitarian Assistance and Security at the Southern Border Act, 2019, Pub. L. 116-26

2. At this time the Central American countries of El Salvador, Guatemala and Honduras are not mandatory notification countries. Mexico is not a mandatory notification country, but the U.S. does have a bilateral agreement that confers similar protocols for minors, therefore Mexican consulate officials will be given access to UAC under similar arrangements as a mandatory notification country.

3. See Exhibit 1, para. C of the Flores settlement agreement.

4. If there has been a court ordered termination of parental rights, a fear that the child is a victim of abuse or trafficking, or that contacting the parent or legal guardian would place the UAC in danger, the care provider will contact the consulate without the parent/legal guardian’s permission (unless the child is claiming credible fear or asylum). If the care provider is unsure, they should immediately elevate their concerns to the ORR/FFS assigned to the care provider.

5. For report templates, see https://www.grants.gov/web/grants/forms.html

6. The UC Portal has a firewall in place to prevent access outside the United States and its territories.]

7. Sponsors may be required to pay for the transport of a UAC (and the travel of any escorts). See Section 2.82, Transfer of Physical Custody [anandihospital.com/programs/orr/resource/children-entering-the-united-st...]

8. For PLE reporting purposes, an outbreak is defined as four or more cases of an infectious disease (e.g., influenza, norovirus, strep throat) within a 2-week period. Individual cases of notifiable diseases are reportable to ORR through other mechanisms. Care providers must also be aware of notifiable disease and outbreak reporting requirements in their States, as outlined in Section 3.4.6 Management of Communicable Diseases.

9. UC case files and program records should be maintained and shared in adherence to what is set out in the System of Records Notice for the Unaccompanied Children’s program 81 FR 46682, or any updated Systems of Records Notice as is published for the Unaccompanied Children’s program.

10. As a matter of discretion ORR treats information maintained in ORR system of records on non-U.S. persons, including case files containing information about children and sponsors, as being subject to the provisions of the Privacy Act. OMB guidance allowing agencies discretion to treat mixed systems as subject to the Privacy Act, OMB Privacy Act Implementation: Guidelines and Responsibilities, 40 Fed. Reg. 28948  (PDF), 28951 (July 9, 1975). Specifically, the 1975 OMB guidance states:Files relating solely to nonresident aliens are not covered by any portion of the [Privacy] Act. Where a system or records covers both citizens and nonresident aliens, only that portion which relates to citizens or aliens is subject to the Act, but agencies are encouraged to treat such systems as if they were, in their entirety, subject to the Act.

11. The Joint Explanatory Statement on Consolidated Appropriations, 2021-Division H  (PDF) directs ORR to develop specific policies and procedures regarding the confidentiality of counseling and mental health services provided to UC, as well as all related documentation, consistent with applicable child welfare laws and regulations, and to ensure care providers are informed of such policies.

12. The House Report 116-450  (PDF) directs ORR to refrain from sharing mental health information with immigration court for master calendar hearings where the court is not making decisions about a child’s custody. The House Report 116-450  (PDF)  further restricts ORR from sharing mental health records with EOIR unless ORR or the care provider is appearing as party in a legal proceeding.

13. ORR tries to provide for the veracity of who the parent or legal guardian is based on its records.

14. Diagnosed developmental disability in this context refers to a diagnosed condition that impacts the child’s cognitive capacity to consent. Examples of this would include, but are not limited to an intellectual disorder, neurocognitive disorder, or severe psychiatric disorder. The assessment of whether a child can consent to release of records must be determined by a physician, nurse practitioner, psychologist, or psychiatrist, following a diagnosis of a cognitive disorder that impacts capacity to consent. Diagnosis of a disability alone is not sufficient to determine whether a child has the capacity to consent for release of their information. If ORR reasonably believes there is a competency concern, while pending the diagnosis or assessment, ORR could make a best interest determination on behalf of the child.

15. ORR refers children who are child trafficking victims and other vulnerable children to be appointed a Child Advocate (see 8 U.S.C. 1232(c)(6)). Under the authorities of the TVPRA, ORR refers children who have a developmental disability, tender age children, children who are pregnant or parenting, children who are placed in a restrictive or therapeutic setting, children who are within six (6) months of aging out where family reunification is unlikely, and children who have been a victim of a crime or human trafficking to be appointed a Child Advocate.

16. If the records request is from a government agency (federal, state, or local), ORR will notify a child’s attorney of record or Child Advocate if assigned of the records request to provide notice of the request. The child’s attorney of record and Child Advocate will be given an option to notify ORR within two (2) business days of receipt if there is any objection to the release of this information.

17. In general, a “lawfully-issued” subpoena is a subpoena was that was issued in accordance with applicable law. ORR staff and care providers should consult with their general counsel to determine if a subpoena was lawfully-issued.

18. Note that a copy of this form must be provided to the child’s LSP or attorney of record, and Child Advocate after provision to EOIR.

19. For children under the age of 14 or children with a diagnosed developmental disability, the care provider should ask the child’s parents for their consent for their contact information to be shared with the LSP.

20. ORR notifies the LSP whenever ORR finds out there is a removal order pursuant to MPP, whether before or after the KYR and legal screening are conducted. ORR also notifies the LSP before transfer of the child with an MPP removal order to another care provider facility.

21. In general, this policy describes information sharing policies regarding children in ORR care who were separated from parents/legal guardians by DHS at the southern border, as described in Ms. L. v. U.S Immigr. & Customs Enf't ("ICE"), 310 F. Supp. 3d 1133 (S.D. Cal. 2018), modified, 330 F.R.D. 284 (S.D. Cal. 2019), and enforcement granted in part, denied in part sub nom. Ms. L. v. U.S. Immigr. & Customs Enf't (“ICE”), 415 F. Supp. 3d 980 (S.D. Cal. 2020). Where the circumstances of separated children in ORR care differ from those described by the Ms. L. litigation, or by other legal requirements (e.g., House Report 116-450), this sub-section may not apply.

22. The child’s photograph may not be shared with DHS or EOIR absent one of the covered exceptions outlined in UC Policy Guide Section 5.10.2 Limits to Sharing Information with DHS and EOIR.

23.  ORR will provide records to OIG and GAO in compliance with 45 CFR 75.364 § 75.364 Access to records.

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