Form A-7 Notification of Concern

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Notification of Concern Form A-7
The Paperwork Reduction Act Of 1995 (Pub. L. 104-13) Statement Of
Public Burden. OMB 0970-0547

Event Details
Placement
Incident Information
Alleged Perpetrator(s)

Status

Pending
supervisor 

approval

Completed

05 / 15 / 24

PRS case manager

Incident Summary and Response
Agencies and Persons Contacted

Submission Details

Child Information
This information is populated from UC Portal.
Child name

A#

Elena Domingo

9021456876

Also known as (AKA)

Date of birth

Lena

05 / 13 / 12

Age

Gender

12

F

Supervisor review

Country of birth

Discharge date

Argentina

04 / 18 / 24

Care provider facility

Phone number

Children's Home Society

816 456-9875

Sponsor Information
This information is populated from UC Portal. Review for accuracy and
provide updates in the Placement section.
Sponsor name

Sponsor category

Theresa Sherman

2A

Sponsor relationship to child

Date of birth

Grandmother

09 / 17 / 68

Gender

Country of birth

F

Argentina

Address

City

110 Southern Pk w y

Apartment 2L

Kingston

State

Zip code

NY

11232

Primary phone

B

212 201-2200

917 201-2200

ackup phone number

Do you plan to enter a flag in UC Portal?

No

Yes

You can flag the sponsor, their address, a household member, or the alternate

caregiver in UC Portal.

Event Details
Date reporting party informed of
event

Date of event
MM / DD / YY

MM / DD / YY

Location of event
If this event occurred across multiple locations, select the primar y location and
include all other locations in the synopsis of event.

Synopsis of event
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dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

Placement
Is the child living with their sponsor?
Yes

No
Is the child still living at the address on file?
Yes

No
What changed?
Location unknown

Other

More information about unknown location (optional)

Other change

Who are they living with?

First Name

Last Name

Relationship to child

Phone number

Where are they living?

Address

Zip code

State

City

If Lena is living at a different address or with a different caregiver, update their
current location in UC Portal on the Discharge tab.

Incident Information
Notification of concern category
Abuse/Neglect

Verbal or Emotional Abuse
Domestic Violence
Physical Abuse
Sex Trafficking Concerns

Labor Trafficking Concerns
Neglect or Abandonment
Unknown
Sexual Abuse of Minor by Minor
Intentional touching, directly or through clothing, of
another's genitalia, anus, groin, breast, inner thigh, or
buttocks
Penetration of another child's anal, oral, or genital area by a
body part or object
Forcing another child to touch/penetrate genitalia, anus,
groin, breast, inner thigh, or the buttocks of another child
Exposure of buttocks, breast, or genitalia of self or another
person (excluding unintentional, incidental exposure such
as in a bathroom)
K
B

nowingly masturbating in another person's presence

estiality

Sadistic or masochistic abuse
Possession or use of child pornography
Child prostitution
Sexual Abuse of Minor by Adult
Actual or simulated sexual intercourse

Molestation (penetration or touching unrelated to official
job duties of another child's buttocks, breasts, or anal, oral,
or genital area by a body part or object)
Prostitution of a child
Forcing a child to engage in sexual exploitation of another
child
Any display of staff's uncovered buttocks, breast, or
genitalia in the presence of a child

Masturbation
B

estiality

Sadistic or masochistic abuse
Possession or use of child pornography

Voyeurism
Any attempt, threat, or request to engage in any of the
activities above
Sexual Harassment
Repeated and unwelcome sexual advances or requests for
sexual favors
Repeated verbal comments, gestures, phone calls, and/or
all electronic communication that are derogatory or sexual
in nature
Repeated actions of a derogatory or offensive sexual nature
Inappropriate Sexual Behavior
Staff Code of Conduct & Boundary Violation ("staff" refers to care
provider facility staff)
Failing to confine relationships with unaccompanied
children, families and sponsors to within scope of duties
Cohabitating with a child before the child turns 21 years old

Having any contact with any child outside of the care
provider facility beyond scope of duties while the child is in
ORR care or before the child turns 21 years old
Engaging in a romantic relationship with a child while the
child is in ORR care or before the child turns 21 years old
Providing letters, gifts, pictures, or any personal contact/
social media information with any child in ORR care or
before the child turns 21 years old
Failing to confine relationships with the child’s family and/
or sponsor to within scope of duties
Failure to report any knowledge, suspicion, or information
about sexual abuse, sexual harassment, or inappropriate
sexual behavior
Child Behavioral Incident with Safety Concerns/ Risk for Self or
Others in Home Community. (Note: this refers to the child’s actions,
not actions of others towards the child)
CPS Involvement
CPS Active Case
CPS Removal
CPS Reported to ORRNCC

NOC reporter initiated concurrent CPS reporting
Criminal Activity or Charges against Released Child
Criminal Activity or Charges against Sponsor that Directly Affect
Child Safety
Death of Released Child (Alert: Notify ORR Immediately)

Media Attention
Placement Disruption with Safety Concerns
Fraud
Actual or Potential Fraud Scheme Targeting Sponsor or
Child
Intentional Information and/or Document Fraud
Serious Medical and/ or Mental Healthcare Issue or Unplanned
Hospitalization
Pregnancy with Complications
Emergency (Alert: Notify ORR Immediately)
Substance Use that Requires Additional Support/Services

Location of Released Child Unknown with Safety Concerns
K

nown Runaway

K

nown Child Abduction

Unknown
Other Sponsor-Related Concerns
Lost Contact with Sponsor and/or Released Child with
Safety Concerns (Note: loss of contact alone is not a safety
concern)
Unable to Establish Contact with the Sponsor or Released
Child within 30 Days of Release or Referral Acceptance
How was this child involved?
Victim

Other

Other way the child was involved
Lena was also involved in this other way

Alleged Perpetrator(s)
Add alleged perpetrator

Alleged Perpetrator
Full name of alleged perpetrator
Samantha Jessamy
Type of alleged perpetrator
Non-staff adult

Other

Other type of alleged perpetrator
Lena’s teacher
Remove

Alleged Perpetrator
Full name of alleged perpetrator
Duane Reese
Type of alleged perpetrator
Non-staff adult

Other

Other type of alleged perpetrator
Teacher’s assistant
Remove

Incident Summary and Response
Summary of incident
Maecenas vehicula consectetur mi, id feugiat orci consectetur in.
Aliquam tristique molestie posuere. Aliquam erat volutpat. Sed in
dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

Maecenas vehicula consectetur mi, id feugiat orci consectetur in.
Aliquam tristique molestie posuere. Aliquam erat volutpat. Sed in
dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

Maecenas vehicula consectetur mi, id feugiat orci consectetur in.
Aliquam tristique molestie posuere. Aliquam erat volutpat. Sed in
dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

Maecenas vehicula consectetur mi, id feugiat orci consectetur in.
Aliquam tristique molestie posuere. Aliquam erat volutpat. Sed in
dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

48 characters left

PRS case manager response and intervention
Maecenas vehicula consectetur mi, id feugiat orci consectetur in.
Aliquam tristique molestie posuere. Aliquam erat volutpat. Sed in
dapibus lacus, vel semper nisl. Curabitur pellentesque facilisis justo.
Morbi aliquam consectetur elementum. Proin feugiat, libero pharetra
scelerisque vulputate, magna tellus viverra lectus, quis vestibulum mi
nisl id tellus. In blandit nisl suscipit, scelerisque nisl a, ullamcorper mi.
Aliquam tincidunt vel urna sed volutpat. Lorem ipsum dolor sit amet,
consectetur adipiscing elit. Vivamus et purus mauris. Duis facilisis
luctus neque eu bibendum. Nullam ut sapien semper, viverra erat non,
bibendum leo. Quisque volutpat pharetra porta.

Agencies Contacted
Add agency contacted

Agency Contacted
Agency

Type of agency

Date reported

Case number

State

Phone number

Email

Remove

Persons Contacted
Add person contacted

Person Contacted
Full name, title

Type of agency

Date reported

Phone number

Email

Remove

Request edits

Elena Domingo
A# 109303492

Child Information
Sponsor Information

Approve

Last saved 11:05 AM

Tracy Kimmel
-- / -- / --

Supervisor

Sam Nichols

Submitted

-- / -- / --

Verified by

Not verified

PRS provider

KidsCorner

Subcontractor

Kids For America