Form A-10A Emergency Significant Incident Report

OMB 0970-0547 [Valid through MM/DD/YYYY]

 Death of a UC in ORR Custody

---Select---



 Medical Emergency
 Abuse/Neglect in ORR Care
 Behavioral Incidents that threaten immediate
safety

Type of Abuse: ---Select---



Alleged Perpetrator: ---Select---

 Use of a Weapon

 Self-Harm with medical intervention

 Harm to Others

 Suicide Attempt/Gesture



 Other
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 urgent situations in which there is an immediate threat to a child's safety and well-being that require instantaneous action. 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].

 Mental Health Emergency Requiring Hospitalization
 Unauthorized Absence
 Other

Specify:

 Escape

 Attempted Escape