Form P-10B Placement Confirmation

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Welcome: Liane

UC Basic Information
First Name:

Nam Test

AKA:

Last Name:

UCP 1940

Status:

ADMITTED

Date of Birth:

7/4/2011 (Age 11)

Admitted Date:

12/9/2022

A#:

497878598

Length of Stay:

202 Days

Country of Birth:

Malaysia

Current Program:

A New Leaf – Dorothy Mitchell

Gender:

F

Portal ID:

692099

Placement Confirmation
Request Details
Requested Program Type

Requester Name

Requester Title

Requester Phone

Placement Details
Receiving Program*
Date Placement Accepted*

Select a Program
mm/dd/yyyy

Receiving Program POC
Receiving Program POC Phone

ORR Placement Confirmation Decision
ORR Decision Maker Name*
Date of ORR Decision*

mm/dd/yyyy

ORR Decision Maker Comments*

32000 characters left.
ORR Decision*

Approve
Disapprove
On Hold (Provide Detail in Comments)

COA

Scheduled Transfer Date
Child's Attorney Contacted
Next Scheduled Court Appearance

mm/dd/yyyy

Yes

No

mm/dd/yyyy

Provide reason if there is less than
48 hours notice to ICE:

Departure/Arrival Information
Departure Date
Transporting Staff Name

mm/dd/yyyy

Departure Time
Transporting Staff Title

Transporting Staff Comments

2000 characters left.

Arrival Date

Arrival Time

Receiving Staff Name

Receiving Staff Title

Receiving Staff Comments

2000 characters left.
Submit Placement

Save Draft

Cancel Placement

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR to process recommendations
and decisions for placement into a specific care provider program once a transfer request is approved. Public reporting burden for this collection of information is estimated to average
0.17 hours per grantee case manager and 0.17 hours per contractor case coordinator (a total of 0.34 hours), including the time for reviewing instructions, gathering and maintaining the
data needed, and reviewing the collection of information. This is a mandatory collection of information (Homeland Security Act, 6 U.S.C. 279). An agency may not conduct or sponsor,
and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB
control number. The OMB control number is 0970-0554 and the expiration date is 06/30/2026. If you have any comments on this collection of information please contact
UCPolicy@acf.hhs.gov.