Form A-9C Non-Emergency Significant Incident Report

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#:

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Length of Stay:

System-generated

Country of Birth:

Auto-populated

Current Program:

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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:

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Auto-populated
System-generated

Child-Level Event
 Emergency SIR
Report Status:*

 Open  Closed

 Non-Emergency SIR

Date Report Opened:

Non-Emergency SIR Category (Select all that apply)

▢ Abuse/Neglect by Adult

 Behavioral Note

▢ Non-medical child neglect
▢ Physical abuse

 Historical Disclosure
Date Report Closed:

▢ Behavioral Safety Measure

▢ Child Behavioral Concerns That Threaten Safety
▢ External Threats to UAC
▢ Healthcare Error
▢ Inappropriate Sexual Behavior
▢ Incidents Involving Law Enforcement On-Site
▢ Intentional Document/Information Fraud
▢ Mental Health Concerns
▢ Request for Termination of Pregnancy
▢ Runaway Attempt
▢ Sexual Harassment
▢ Staff Code of Conduct & Boundary Violation

▢ Verbal or emotional abuse
▢ Physical restraint
▢ Seclusion

▢ Soft restraints

▢ Actual or potential fraud schemes
▢ Labor trafficking concern or risk identified
▢ Gang affiliation reported

▢ Sex trafficking concern or risk identified
▢ Threats related to crime or organized crime

▢ Destruction of property
▢ Physical aggression

▢ Health-related neglect
▢ Inappropriate health intervention (e.g., incorrect
procedure, incorrect patient)

▢ Use of drugs or alcohol
▢ Verbal aggression

▢ Medication/vaccine administration error

▢ Arrest
▢ Interview

▢ Investigate/Response
▢ Search

▢ Repeated gestures of a derogatory or offensive
sexual nature
▢ 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

▢ Hallucinations
▢ Homicidal ideations

▢ Cohabitating with a UAC before the child turns 21
years old
▢ Engaging in a romantic relationship with a UAC
while the child is in ORR care or before the child turns
21 years old
▢ Failing to confine relationships with children, their
families, and their sponsors to within scope of duties
▢ Failing to report any knowledge, suspicion, or
information about sexual abuse, sexual harassment,
inappropriate sexual behavior, or any other form of
abuse/neglect
▢ Failing to report a code of conduct violation

▢ Self-harm that does not require emergency medical
intervention
▢ Suicidal ideation without a plan

▢ Having any contact with any UAC 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
▢ Providing letters, gifts, pictures, or any personal
contact/social media information with any UAC in
ORR care or before the UAC turns 21 years old
▢ Engaging in sexual contact with anyone while on
duty or while acting in the official capacity of their
position
▢ Threatening a child with incident reporting or
behavioral notes to regulate their behavior or for any
other reason

▢ Threatening a child with legal, immigration,
sponsor unification, or asylum case consequences to
regulate their behavior or for any other reason

Individuals Involved (Section only appears if user selects Abuse/Neglect by Adult, Inappropriate Sexual Behavior, Sexual Harassment, or Staff Code of Conduct & Boundary
Violation)

Type of allegation*
Staff and UAC
UAC and UAC nonconsensual
Non-Staff Adult and UAC
Non-UAC Child and UAC
Other
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

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 or will the child be referred for healthcare services? *

 Yes  No

Specify Type(s) of Healthcare Services: *

▢ Medical

Appears if user selects “Yes”
Describe the healthcare services that were or
will be provided: *

▢ Mental Health/Behavioral

Disciplinary Action for
Staff

▢ Dental

Appears if user selects “Yes”
Staff Response and Intervention:*
Actions Taken for Impacted Child:*

(Field only appears if user selects Abuse/Neglect by Adult, Inappropriate Sexual Behavior, Sexual Harassment, or Staff Code of
Conduct & Boundary Violation)

Actions Taken for Exhibiting Child or Alleged
Adult Perpetrator:*

(Field only appears if user selects Abuse/Neglect by Adult, Inappropriate Sexual Behavior, Sexual Harassment, or Staff Code of
Conduct & Boundary Violation)

Actions Taken for Witnesses:*

(Field only appears if user selects Abuse/Neglect by Adult, Inappropriate Sexual Behavior, Sexual Harassment, or Staff Code of
Conduct & Boundary Violation)

Follow-up and/or Resolution:

(Field only appears if user DOES NOT select Abuse/Neglect by Adult, Inappropriate Sexual Behavior, Sexual Harassment, or Staff
Code of Conduct & Boundary Violation)

ORR Recommendations:

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?

 Yes  No

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 CPS?*

 Yes  No

Was the incident investigated
by CPS?

Yes
No
To Be Determined
Unknown

Date of Report:

Time of Report:

Date Notified the
Incident will be
investigated:

Case/Confirmation
Number:

Date of Report:

Time of Report:

Officer Name:

Officer Badge:

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 Local Law
Enforcement?*

Was the incident investigated
by Local Law Enforcement?

 Yes  No

Yes
No

To Be Determined
Unknown
Explain
Disposition of Investigation:
Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed
Result/Findings of
Investigation:
Attach Reports/Findings:

Was it reported to DCPI?*

 Yes  No

Was the incident investigated
by DCPI?

Yes
No
To Be Determined
Unknown

Date of Report:

Time of Report:

Date Notified the
Incident will be
investigated:

Case/Confirmation
Number:

Date of Report:

Time of Report:

Explain
Disposition of Investigation:
Substantiated Tier I
Substantiated Tier II
Not Substantiated
Unfounded
Administratively Closed
Was it reported to DOJ/FBI?*

 Yes  No

Explain
Was it reported to OIG?*

 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 DHS*
Explain
Was it reported to Office on
Trafficking in Persons
(Shepherd)?*

Eligibility
Interim Assistance
Denial

Explain
Is an Incident Review form
required? *

Date Form
Due:

 Yes  No

Attach Incident Review form:

Notifications: *
Title
Attorney of
Record/Legal Service
Provider

Name

Date Notified

Time Notified

Method of Notification
Phone call
In-person
Email
Messaging app
Mail
Other

Specify

Parent/Legal Guardian
Sponsor
Child Advocate (if
applicable)

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 situations that affect, but do not immediately threaten, safety and well-being of a child 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].