Form A-9D Historical Disclosure

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 UC
Portal Discharge Tab

See UAC Policy Guide Section 4 and 5 for related policies.

Child-Level Event Information
Location of Event:

Auto-populated

Specific Location:

Approximate Date of Event:

Auto-populated

Event ID:

Date Care Provider Became
Aware of Event:

Auto-populated

Short Synopsis:

Auto-populated

Time Care Provider Became
Aware of Event:

Auto-populated
System-generated

Auto-populated

Child-Level Event
 Emergency SIR
Disclosure Status:*

 Open  Closed

Historical Disclosure Category (Select all that apply)

 Non-Emergency SIR

 Behavioral Note

Date Disclosure Opened:

 Historical Disclosure
Date Disclosure Closed:

▢ Violation of Civil Rights/Liberties in DHS Custody

▢ Past Abuse/Neglect Not in ORR Care or DHS
Custody

▢ Self-Disclosed Juvenile Delinquency

Incident Information:
Did someone other than this child initially
report the incident?*
Name

▢ Conditions of detention
▢ Disability accommodation
▢ Excessive force or inappropriate use of force
▢ Fourth Amendment (confiscation of
documents/property)
▢ Intimidation, threat, or improper coercion
▢ Legal access/Due Process rights
▢ Undocumented separation from parent/legal
guardian
▢ Undocumented separation from minor sibling

▢ Medical/mental health care
▢ Privacy Violation
▢ Religious Accommodation
▢ Retaliation
▢ Restraints or isolation
▢ Sexual abuse, sexual harassment, or inappropriate
sexual behavior
▢ Previous enrollment in DHS Migrant Protection
Protocols program

Alleged perpetrator:

Parent/Guardian/Caregiver
Military Personnel
Police/Government Official
Foot Guide/Coyote
Other Adult
Other Child
N/A
▢ Physical abuse
▢ Verbal or emotional abuse
▢ Neglect/abandonment
▢ Sexual abuse
▢ Sexual harassment
▢ Labor trafficking concerns
▢ Sex trafficking concerns
▢ Smuggling

▢ Forced marriage with adult still in home country
▢ Forced marriage with adult in United States
▢ Domestic violence
▢ Adolescent/teen dating violence
▢ Inappropriate health intervention
▢ Past mental health concerns
▢ Witnessing traumatic events
▢ Other harmful or traumatic events

▢ Self-Disclosure of past juvenile delinquency charges
▢ Self-Disclosure of past juvenile delinquency convictions
▢ Self-Disclosure of past harm to others that lacks a charge or conviction
 Yes  No

Type

A#

Title

Specify

Appears if user selects UAC

Appears if user selects Staff

UAC
Staff
Non-UAC Child
Non-Staff Adult

Appears if user selects NonUAC Child or Non-Staff
Adult

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

▢ Medical

▢ Mental Health/Behavioral

▢ Dental

Appears if user selects “Yes”
Staff Response and Intervention:*
Follow-up and/or Resolution:
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

Date of Report:

Time of Report:

Date Notified the
Incident will be
investigated:

Case/Confirmation
Number:

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 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:

Date of Report:

Time of Report:

Date Notified the
Incident will be
investigated:

Case/Confirmation
Number:

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

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:

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?

Date Notified the
Incident will be
investigated:

Case/Confirmation
Number:

 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:

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?*
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

Notifications: *
Title

Name

Date Notified

Time Notified

Method of Notification

Specify

Phone call
In-person
Email
Messaging app
Mail
Other

Attorney of
Record/Legal Service
Provider

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 the safety and well-being of a child that occurred before the child entered 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].