Form A-9 Program Level Event Report

OMB 0970-#### [Valid through MM/DD/20YY]
Program Level Event

Event ID:
Date of Event:

Time of Event:

Program/Facility:
Category of Event:
Specify:

Sub-Category:

Synopsis of Event:
Incident Information
Incident Information
Location of
Incident:

Specify:

Description of
Incident:
Was the UAC or
Anyone Else
Injured? (If Yes,
SIR must be
created)
Specify:
Internal
Investigation?:

Yes

No

Yes

No

Date
Investigation
Completed:

Results/Findings
of Investigation:
Actions Taken
Was the UAC or
Anyone Else
Evacuated?
Specify:
Staff Response
and
Intervention:

Yes

No

Follow-up and/or
Resolution:
Reporting
Reported to State Licensing:
Was the Incident
Investigated?

Yes No N/A
Yes No N/A

State Licensing
Date of Report:
Date Notified the
Investigation will be
Investigated:

Time of Report:
Case/Confirmation
Number:

Specify:
Results/Findings of
Investigation:

Law Enforcement
Reported to Law
Enforcement:

Yes No N/A

Date of Report:

Time of Report:

Was the Incident
Investigated?

Yes No N/A

Date Notified the
Investigation will be
Investigated:

Case/Confirmation
Number:

Specify:
Results/Findings 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 inform ORR of events may affect the entire care provider facility, such as an active shooter or natural disaster. 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 [email protected].

ORR Notifications
Name

Agency/Title
ORR/FFS
ORR/PO
ORR Intakes
Medical
Coordinator
Case
Coordinator
CFS
SIR Hotline

Date Notified

Time Notified

Title

Email

Email

Telephone number

Reporter and Follow-Up Contact
Type
Staff Filling
Report
Contact for
Follow-Up

Name

Telephone number