Form A-9A Child-Level Event

UAC Basic Information
First Name:

Auto-populated

AKA:

Auto-populated

Last Name:

Auto-populated

Status:

System-generated

Date of Birth:

Auto-populated

Admitted Date:

System-generated

A#:

Auto-populated

Length of Stay:

System-generated

Country of Birth:

Auto-populated

Current Program:

Auto-populated

Sex:

Auto-populated (options for
male and female only)

Portal ID:

System-generated

Physical Location of Child:

Auto-populated from
UAC Portal Discharge Tab

Child-Level Event Information
Location of Event

Event ID:
Current Care Provider Facility
Previous Care Provider Facility
Community
Out-of-Network Placement
DHS Custody
Country of Origin
Journey to U.S.
U.S. Interior (before entering DHS or ORR custody)

Specify Program
List of all care provider facilities

Appears if user selects Current Care Provider
Facility or Previous Care Provider Facility

Level of Care

Auto-populated based on program selected

Specify Location

Appears if user selects Current Care Provider
Facility or Previous Care Provider Facility. Open text
field appears if Other is selected.

Individual Foster Home
Facility Dining Area
Facility Bedroom or Dormitory Area
Facility Health Clinic
Facility Recreational Area
Facility Restroom or Shower
Facility School Area
Other Facility Location

CBP Custody
ICE Custody
Unknown
Hospital or other healthcare facility
School
Field Trip
Other

Appears if user selects DHS Custody

Appears if user selects Community. Open text field
appears if Other is selected.

Specify Out-of-Network Facility

Appears if user selects Out-of-Network Placement

Specify Out-of-Network Level of Care

Appears if user selects Out-of-Network Placement

Approximate Date of Event: Month/Year

Appears if user selects DHS Custody, Country of
Origin, Journey to U.S., or U.S. Interior, not DHS or
ORR custody
Appears if user selects Current Care Provider
Facility, Previous Care Provider Facility, Group
Home, Foster Home, Community (field trip or
outside the foster home), or Out-of-Network
Placement

Date of Event:

Time of Event:

Date Care Provider
Became Aware of Event:

Time Care Provider
Became Aware of Event:

Short Synopsis:

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
document events occurring in and outside of ORR care that must be reported to ORR. Public reporting burden for this collection of information is estimated to average 0.17 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. The OMB control number is 0970-XXXX and the expiration date is
MM/DD/YYYY. If you have any comments on this collection of information please contact [email protected].