Form A-7 Notification of Concern Addendum

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Addendum
Updates to Placement
Updates to Incident Information
Additional Agencies Contacted
Additional Persons Contacted

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Notification of Concern – Addendum

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Elena Domingo
A# 109303492

Addendum

Submission Details

Addendum description

Status

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Updates to Placement
Is the child living with their sponsor?
es

Y

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

Y

No
W

hat changed?
Location unknown

Other

More information about unknown location (optional)

Other change

W

ho are they living with?

First Name

Last Name

Relationship to child

Phone number

W

here are they living?

Address

ip code

State

City

Z

Updates to 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)
Knowingly masturbating in another person's presence
Bestiality

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
Bestiality

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
Known Runaway
Known 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

Additional Agencies Contacted
Add agency contacted

Agency Contacted
Agency

Type of agency

Date reported

Case number

State

Phone number

Email

Remove

Additional Persons Contacted
Add person contacted

Person Contacted
Full name, title

Type of agency

Date reported

Phone number

Email

Remove

Completed

Pending

supervisor 

approval
05 / 15 / 24

PRS case manager Tracy Kimmel
Supervisor review

-- / -- / --

Supervisor

Sam Nichols

Submitted

-- / -- / --

Verified by

Not verified

PRS provider

KidsCorner

Subcontractor

Kids For America