Form A-10B Emergency Significant Incident Report Addendum

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

First Name:
Last Name:
Date of Birth:

Photo of Minor

Status:
AKA:
Gender:

A No.:
Age:
Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:
Event Type: SIR Event
Date of
Event:

LOS:
LOC:
Current Program:
Current Location:

Time of
Event:

Event ID:

Synopsis of
Event:
Significant Incident Report   (Addendum)

Emergency SIR

SIR
Emergency SIR

Death In Care Provider Facilty

---Select---

Medical Emergency Requiring Immediate Hospitalization
Other
Specify: 
Incident Information:

Did the incident take place at
another care provider facility?

Yes

No Care Provider Name:
Care Provider City:

Care 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 (History)

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

Yes

No

Specify:
Actions Taken
  Staff Response and Intervention (History)

Staff Response and Intervention
  Follow-up and/or Resolution (History)

Follow-up and/or Resolution:
  Recommendations (History)

Recommendations:
Reporting:

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:

Explain
Results/Findings of Investigation:
Attach Reports/Findings:
Is CPS Different From State
Licensing:

Yes

No

Reported To CPS:

Yes

No

Was the Incident Investigated?

Yes

No

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

Time of Report:
Case/Confirmation
Number:

Explain
Results/Findings of Investigation:
THE PAPERWORKAttach Reports/Findings:
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
an Emergency 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.

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:

Explain
Results/Findings of Investigation:
Attach Reports/Findings:
ORR Notifications:

Name

Agency/Title

Date Notified Time Notified

Telephone
Number

Email

ORR/PO
Medical
Coordinator
Case Coordinator
CFS
SIR Hotline
ORR/FFS
Other Notifications:

Is this an SIR for a Runaway?

Yes

No

Title

Name

Date Notified Time Notified

ICE Juvenile
Coordinator

Method of
Notification

Specify

Phone
Reporter and Follow-Up Contact:

Type
Staff Filing Report
Contact for Follow-Up

1

Name

Title

Email

Telephone Number