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pdfOMB 0970-#### [Valid through MM/DD/20YY]
UAC Basic Information
First Name:
Last Name:
Photo of Minor
Status:
AKA:
Date of Birth:
A No.:
Age:
Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:
Event Type: SIR Event
Date of
Event:
Gender:
LOS:
LOC:
Current Program:
Current Location:
Time of
Event:
Event ID:
Synopsis of
Event:
Significant Incident Report
Emergency SIR
SIR
SIR
Alleged Perpetrator:
Abuse/Neglect in ORR Care
Sexual Abuse SIR
TYPE OF INCIDENT/INDIVIDUALS INVOLVED
Type of Incident:
Type of Allegation:
How was this UAC involved?
Were Other UAC Involved
Yes
No
Name
Were Staff Present of Involved in the
Incident
Yes
A-Number
Role
Specify
Title
Role
Specify
No
Name
Incident Information:
Did the incident take place at
another care provider facility?
Yes
No Care Provider Name:
Care Provider City:
-- Select Provider Name --- Select Provider City -- Care Provider State: -- Select Provider State --
Location of
Incident:
Date Reported To
Care Provider:
Time Reported To
Care Provider:
Other Specify:
Date Reported To
ORR:
Time Reported To
ORR:
Description of Incident: (Full
Description of Incident)
Was the UAC or Anyone Else
Injured?:
Yes
No
Specify:
Actions Taken
Staff Response and Intervention
Actions Taken for Victim:
Action Taken for Alleged
Perpetrator:
Follow-up Regarding Individuals
Involved:
Recommendations:
Reporting:
Reported To CPS:
Yes
No
Date of
Report:
Time of
Report:
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR care provider programs to inform ORR of allegations of sexual
harassment, sexual abuse, and inappropriate sexual behavior. Public reporting burden for this collection of information is estimated to average 0.333 hours per response, 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. If you have any comments on this
collection of information please contact UACPolicy@acf.hhs.gov.
Was the Incident Investigated?
Yes
No
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Progress of Investigation:
Results/Findings of Investigation:
Attach Reports/Findings:
Is CPS Different From State
Licensing:
Yes
No
Reported To State Licensing:
Yes
No
Was the Incident Investigated?
Yes
No
Date of
Report:
Date Notified the
Incident will be
investigated:
Time of
Report:
Case/Confirmation
Number:
Progress of Investigation:
Results/Findings of Investigation:
Attach Reports/Findings:
Reported To Local Law
Enforcement:
Was the Incident Investigated?
Yes
No
Yes
No
Date of
Report:
Time of Report:
Officer Name:
Officer Badge:
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Progress of Investigation:
Results/Findings of Investigation:
Attach Reports/Findings:
Reported To DOJ:
Date of
Report:
Yes No
Time of
Report:
Notes:
ORR Notifications:
Name
Agency/Title
Date Notified Time Notified
Telephone
Number
Email
ORR/FFS
ORR/PO
Case Coordinator
CFS
SIR Hotline
Medical
Coordinator
Other Notifications:
Title
Name
Date Notified Time Notified
Attorney of
Record
Parent/Legal
Guardian
Child Advocate
(If Applicable)
Method of
Notification
Specify
Phone
Phone
Phone
Reporter and Follow-Up Contact:
Type
Staff Filing Report
Contact for Follow-Up
Name
Title
Email
Telephone Number
| File Type | application/pdf |
| File Modified | 2020-03-26 |
| File Created | 2019-12-12 |