Form A-10F Sexual Abuse Significant Incident Report Addendum

OMB 0970-#### [Valid through MM/DD/20YY]
UAC Basic Information

First Name:

Photo of Minor

Status:

Last Name:
Date of Birth:
A No.:
Age:
Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:

AKA:
Gender:
LOS:
LOC:
Current Program:
Current Location:

Event Information

Event Type: SIR Event
Date of
Event:

Time of
Event:

Event ID:

Synopsis of
Event:

Last Name

First Name

AKA

Status

DOB

A Age Gender
Number

COB

LOS LOC

Current Current
Care
Care Admitted Role in
Provider Provider Date Incident
City
State

TYPE OF INCIDENT/INDIVIDUALS INVOLVED

Type of Incident:

Type of Allegation:
Staff Information

Name

Title

Role

Specify

Incident Information:

Did the incident take place at
another care provider facilty?

Care Provider
Name:

Yes No

-- Select Provider Name --

Care Provider
-- Select Provider City -City:
Date Of
Incident:
Date Reported To Care
Provider:

Location of Incident:

Date Reported To
ORR:

Other Specify:

Care Provider
-- Select Provider State -State:
Time Of
Incident:
Time Reported To Care
Provider:
Time Reported To
ORR:

Description of Incident: (Full
Description of Incident)
Was the UAC or Anyone Else
Injured?:

Yes

No

If Yes, 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:
Was the Incident Investigated?

Yes No
Yes No

Date of
Report:
Case/Confirmation
Number:

Time of
Report:
Date Notified the Incident will be
investigated:

Progress of Investigation:
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 provide additional information obtained after
Results/Findings of
a Sexual Abuse Significant Incident Report has been submitted to ORR. Public reporting burden for this collection of information is estimated to average 0.25 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.

Investigation:
Attach Reports/Findings:

Is CPS Different From State
Licensing:
Reported To State Licensing:
Was the Incident Investigated?

Yes

No

Yes No
Yes No

Progress of Investigation:

xxx

Results/Findings of
Investigation:

xxx

Date of
Report:
Case/Confirmation
Number:

Time of
Report:
Date Notified the Incident will be
investigated:

Attach Reports/Findings:

Reported To Local Law
Enforcement:

Yes No

Date of
Report:
Officer
Name:

Was the Incident Investigated?

Yes No

Case/Confirmation
Number:

Time of
Report:
Officer
Badge:
Date Notified the Incident will be
investigated:

Progress of Investigation:
Results/Findings of
Investigation:
Attach Reports/Findings:

Reported To DOJ:
Reported To EOUSA:
Reported To FBI:
Was the Incident Investigated?

Yes No

Date of
Report:

Time of
Report:

Yes No

Date of
Report:

Time of
Report:

Yes No

Date of
Report:

Time of
Report:

Yes No

Progress of Investigation:
Results/Findings of
Investigation:
Attach Reports/Findings:

Notes
Case Management and Notifications (FFS)

Services/Follow Up for Victim:
Was an Outside Counselor
Offered to the Victim?
If the Victim does not have a
child Advocate, was a Child
Advocate-Recommended?

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Yes

No

Date:

Emergency Contraception?

Yes

No

Date:

Explain:
Lawful-Pregnancy Related
Services?
Explain:

Yes

No

Date:

Did the incident involve the
exchange of bodily fluids?
Was the Victim Taken for a
Forensic Medical Examination?
Explain:
Could the victim UAC be at risk
for pregnancy?
Was the victim provided
information about and access to?
A Pregnancy Test?
Explain:

Services/Follow-up for Perpetrator:
If the Perpetrator was a staff
member, was He/She
Yes
immediately removed from
duties?
Was the Staff Member
Yes
Terminated?
Was the Staff Member
Yes
Reinstated?
Explain:
Medical and Mental Health
Evaluation/Diagnosis/Findings
for Victims or Perpetrator:
Impact on Release/Discharge
Plan:
Updates/Additional Information:

No

Date Staff Member was
removed and placed on
administrative leave:

No

Date of
Termination:

No

Date Reinstated:

Notifications:

Title

Name

Date Notified Time Notified

Attorney of Record
Parent/Legal Guardian
Advocate (If
Applicable)
Service Provider (With
Child’s Consent)

Phone
Phone
Phone
Phone

Care Provider Prevention, Detection, Response Efforts (PO)

Issues Prior to Incident:
Issues with Response to Incident:
Issues Post-Incident:
Recommendations/Advisory
information:
Were Corrective Actions Issued?

Yes

No

Yes

No

Explain:
Attach Corrective Actions and
Follow-Up
Reports/Responses:

Did the Care Provider Facility
Become Compliant with the
Corrective Actions?

Method of
Notification

Date:

Specify

Follow-up/Data Collecting (PSA Coordinator)

Did the Care Provider Complete
and Incident Review Report?
Any Other Follow-Up Notes or
Actions Taken:

Yes

No

Final Disposition of Case:

Investigated

CPS
Findings
Were Charges Filed
Minor
Staff
Other:

Administratively closed
Yes

No

Were Charges Filed
Minor
Staff
Other:

ANumber:

Name:

Title:

Specify: 

Yes

No

Name:

Title:

Specify: 

Investigated
Yes

Minor
Staff
Other:
Were there Findings

Date:
ANumber:

Did the State Licensing
Investigate the Substance of the
Allegation
Findings

Not Investigated

Name:  

State Licensing

Were Charges Filed

Date:

Name:  

Investigated

Local Law Enforcement

Not Investigated

Not Investigated

No

Administratively closed
Yes

No

Date:

Name:  

ANumber:

Name:

Title:

Specify: 
Yes

No

Date:

Explain
Attachments

Investigated

DOJ
Were Charges Filed
Minor
Staff
Other:
If Charges Were Filed, What Was
the Disposition of the Case?
Convicted
Date:
Court:
Conviction:
Sentence:

Yes
Name:  
Name:
Specify: 

No

Not Investigated
Date:
ANumber:
Title:

Explain:
Not Convicted
Charges Dropped
Other, Specify
Date Case Closed:
Notes:
Assigned ORR Staff:
FFS:
PO:
PSA:
CFS:
Reporter and Follow-Up Contact:

Type
Staff Filing Report
Contact for Follow-Up

Name

Title

Email

Telephone Number