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pdfUAC 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
See UAC Policy Guide Section 4 and 5 for related policies.
Child-Level Event Information
Location of Event:
Auto-populated
Specific Program:
Auto-populated
Specific Location:
Date of Event:
Auto-populated
Time of Event:
Auto-populated
Event ID:
Date Care Provider Became
Aware of Event:
Auto-populated
Time Care Provider Became
Aware of Event:
Auto-populated
Short Synopsis:
Auto-populated
Auto-populated
System-generated
Child-Level Event
Emergency SIR
Report Status:*
Open Closed
Emergency SIR Category (Select all that apply)
▢ Death of a UAC
Non-Emergency SIR
Behavioral Note
Date Report Opened:
Historical Disclosure
Date Report Closed:
▢ Incident Involving Weapons
▢ Medical Emergency
▢ Sexual Abuse of Child by Adult
▢ Sexual Abuse of Child by Child
▢ Possession
▢ Use
▢ Acute illness
▢ Exacerbation of a chronic medical condition
▢ Injury or misadventure
▢ Pregnancy-related
▢ Psychiatric admission
▢ Severe abuse/neglect
▢ Severe medical error
▢ Severe mental health symptoms, without self-harm
▢ Severe self-harm
▢ Substance use
▢ Suicidal ideation with a plan
▢ Bestiality
▢ Child prostitution
▢ Exposure of buttocks, breast, or genitalia of self or
another person (excluding unintentional, incidental
exposure such as in a bathroom)
▢ Forcing a child to touch/penetrate genitalia, anus,
groin, breast, inner thigh, or the buttocks of
themselves or another child.
▢ Intentional touching, directly or through the
clothing, of another's genitalia, anus, groin, breast,
inner thigh, or the buttocks
▢ Knowingly masturbating in another person's
presence
▢ Penetration of another child's anal, oral, or genital
area by a body part or object
▢ Possession or use of child pornography
▢ Sadistic or masochistic abuse
▢ Actual or simulated sexual intercourse
▢ Any display of staff's uncovered buttocks, breast, or
genitalia in the presence of a child
▢ Forcing a child to engage in sexual exploitation of
another child
▢ Molestation (intentional penetration or touching
unrelated to official job duties of a child's genitalia,
anus, groin, breast, inner thigh, buttocks, or mouth by
a body part or object, including kissing, with intent to
abuse, arouse, or gratify sexual desire)
▢ Unauthorized Absence
Individuals Involved
Type of allegation*
Appears if user selects Sexual Abuse of Child by Adult or
Sexual Abuse of Child by Child
Staff and UAC
UAC and UAC nonconsensual
Non-Staff Adult and UAC
Non-UAC Child and UAC
Other
▢ Bestiality
▢ Masturbation
▢ Possession or use of child or adult pornography
▢ Prostitution of a child
▢ Sadistic or masochistic abuse
▢ Voyeurism
▢ Any attempt, threat, or request to engage in any of
the activities above
Did someone other than this child initially reported the
incident?*
Name
Yes No
Type
A#
Appears if user selects UAC
Title
Appears if user selects Staff
Specify
Appears if user selects NonUAC Child or Non-Staff
Adult
A#
Role
Specify
UAC
Staff
Non-UAC Child
Non-Staff Adult
How was this child involved?*
Impacted
Exhibiting
Witness
Reporter
Other
Were other UAC involved?*
Yes No
Name
Impacted
Exhibiting
Witness
Reporter
Other
Were staff present or involved in the incident?*
Name
Yes No
Title
Role
Specify
Disciplinary Action for
Staff
Alleged Victim
Alleged Perpetrator
Witness
Reporter
Other
Suspended
Terminated
Reinstated
Retrained
Resigned
N/A
Incident Information:
Full Description of Incident:*
Was the child or anyone else injured?: *
Yes No
Specify:
Actions Taken:
Was or will the child be referred to the local legal service
provider for a follow-up legal consultation? *
Yes No
Was or will the child be referred for appointment of a child
advocate? *
Yes No N/A (child already has a child advocate)
Was the child hospitalized and/or receive serious medical
services? *
Yes No
Appears if user selects Medical Emergency category
Was or will the child be referred for healthcare services? *
Specify Type(s) of Healthcare Services: *
Appears if user selects “Yes”
Yes No
▢ Medical
▢ Mental Health/Behavioral
▢ Dental
Describe the healthcare services that were or
will be provided: *
Appears if user selects “Yes”
Staff Response and Intervention:*
Actions Taken for Impacted Child:*
(Field only appears if user selects Sexual Abuse of Child by Adult or Sexual Abuse of Child by Child)
Actions Taken for Exhibiting Child or Alleged
Adult Perpetrator:*
(Field only appears if user selects Sexual Abuse of Child by Adult or Sexual Abuse of Child by Child)
Actions Taken for Witnesses:*
(Field only appears if user selects Sexual Abuse of Child by Adult or Sexual Abuse of Child by Child)
Follow-up and/or Resolution:
(Field only appears if user DOES NOT select Sexual Abuse of Child by Adult or Sexual Abuse of Child by Child)
ORR Recommendations:
Immediate Phone Call Notifications:
Title
9-1-1
FFS Supervisor
FFS
Intakes Hotline
ICE FOJC
Appears if user selects
Unauthorized Absence
category
NCMEC
Appears if user selects
Unauthorized Absence
category
Name
Date Notified
202-401-5709
1-800-843-5678
Reporting: (Additional fields for each section only appear when the use selects Yes for the first question)
Was it reported to State
Licensing?*
Was the incident investigated
by State Licensing?
Explain
Disposition of Investigation:
Yes No
Yes
No
To Be Determined
Unknown
Date of Report:
Time of Report:
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Time Notified
Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed
Result/Findings of
Investigation:
Attach Reports/Findings:
Was it reported to CPS?*
Yes No
Was the incident investigated
by CPS?
Yes
No
To Be Determined
Unknown
Explain
Disposition of Investigation:
Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed
Result/Findings of
Investigation:
Attach Reports/Findings:
Date of Report:
Time of Report:
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Was it reported to Local Law
Enforcement?*
Was the incident investigated
by Local Law Enforcement?
Yes No
Yes
No
To Be Determined
Unknown
Date of Report:
Time of Report:
Officer Name:
Officer Badge:
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Date of Report:
Time of Report:
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Explain
Disposition of Investigation:
Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed
Result/Findings of
Investigation:
Attach Reports/Findings:
Was it reported to DCPI?*
Was the Incident Investigated
by DCPI?
Yes No
Yes
No
To Be Determined
Unknown
Explain
Disposition of Investigation:
Substantiated Tier I
Substantiated Tier II
Not Substantiated
Unfounded
Administratively Closed
Was it reported to DOJ/FBI?*
Yes No
Date of Report:
Time of Report:
Yes No
Date of Report:
Time of Report:
Yes No
Date of Report:
Time of Report:
Yes No
Date of Report:
Outcome of Report:
Explain
Was it reported to OIG?*
Explain
Was it reported to DHS*
Explain
Was it reported to Office on
Trafficking in Persons
(Shepherd)?*
Eligibility
Interim Assistance
Denial
Explain
Is an Incident Review form
required? *
Attach Incident Review form:
Yes No
Date Form
Due:
ORR Notifications: *
Title
FFS
Name
Date Notified
Time Notified
Method of Notification
Specify
Phone call
In-person
Email
Messaging app
Mail
Other
FFS Supervisor
Field Manager
On-Call Field Staff
PO
[email protected]
Email
SIR Triage
DHUAC
[email protected]
[email protected]
Email
Title
Name
Case Coordinator
CFS
Other Notifications: *
Attorney of
Record/Legal Service
Provider
Parent/Legal Guardian
Date Notified
Time Notified
Method of Notification
Phone call
In-person
Email
Messaging app
Mail
Other
Specify
Child Advocate (if
applicable)
Sponsor
Appears is user selects
“yes” to question above
on hospitalization or
serious medical services
Other Next-of-Kin (if
applicable)
Appears if user selects
Death of a UAC category
Consulate
Appears if user selects
Death of a UAC category
ICE FOJC
Appears if user selects
Unauthorized Absence
or Death of a UAC
category
DHS ERO JFRMU
Appears if user selects
Death of a UAC category
Reporter and Follow-Up Contact:*
Type
Staff Filing Report
Contact for Follow-Up
Name
Title
Email
Telephone Number
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 where there is an immediate threat to a child’s safety and well-being that requires instantaneous action that occur while the child is in ORR
custody. Public reporting burden for this collection of information is estimated to average 1.5 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].
| File Type | application/pdf |
| Author | Herboldsheimer, Shannon (ACF) |
| File Modified | 2025-04-17 |
| File Created | 2025-04-17 |