Form A-9E Behavioral Note

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

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
Note Status:*

 Open  Closed

 Non-Emergency SIR

 Behavioral Note

Date Note Opened:

 Historical Disclosure
Date Note Closed:

REMINDER: Behavioral concerns that result in a medical emergency must be reported as an Emergency Significant Incident Report (SIR). Child behavioral concerns that
threaten safety (e.g., destruction of property, physical aggression, verbal aggression, and use of drugs or alcohol) must be reported as a Non-Emergency SIR.

Behavioral Note Category (Select all that apply)

▢ Behavioral interactions with other children
▢ Behavioral interactions with adult
▢ Individual behavior

Behavior Information:

Who initially reported/observed the
behavior?*
Name

Type

A#
Appears if user selects UAC

Title
Appears if user selects Staff

UAC
Staff
Non-UAC Child
Non-Staff Adult
Type of Behavior:*

Specify
Appears if user selects NonUAC Child or Non-Staff
Adult

 Positive behavior, habit, resilience, personal growth, skill-building, or another meritorious action/trait
 Behavior that merits monitoring in the event a behavioral pattern emerges that requires intervention or support

Description of Behavior:*
Is the behavior part of an established behavioral pattern? *

 Yes

 No

Appears if user selects “Behavior that merits monitoring…”

Is intervention or support required? *

 Yes

 No

Appears if user selects “Behavior that merits monitoring…”

Action Taken:
Was or will the child be referred for
healthcare services? *

 Yes

 No

Appears if user selects “Behavior that merits
monitoring…”
Specify Type(s) of Healthcare Services: *
Appears if user selects “Yes”
Describe the healthcare services that
were or will be provided: *
Appears if user selects “Yes”
Staff Response (if applicable):
Appears if user selects “Positive behavior…”

▢ Medical

▢ Mental Health/Behavioral

▢ Dental

Potential Consequence(s) of Continued
Behavior:*
Appears if user selects “Behavior that merits
monitoring…”
Staff Intervention or Support:*
Appears if user selects “Behavior that merits
monitoring…” and “Yes” for “Is intervention or
support required?”
ORR Recommendations:*
Appears if user selects “Behavior that merits
monitoring…” and “Yes” for “Is intervention or
support required?”

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 behaviors or observations about children that highlight positive events or developments in the children’s daily life while in ORR custody and to document patterns of
behavior that potentially merit intervention or support over time. Public reporting burden for this collection of information is estimated to average 0.5 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].