Form A-10 Program-Level Event Report

Program-Level Event Report
See UAC Policy Guide Section 5 for related policies.
Report Status:*

 Open  Closed

Date Report Opened:

Date Report Closed:

Event Information
Date of Event: *

Time of Event: *

Specify Program: *

Level of Care:

Event ID:

System-generated

Auto-populated based on program selected

Short Synopsis: *

Category (Select all that apply)

▢ Facilities Issues
▢ Video Monitoring Disruption
▢ Infectious Disease/Health and Safety Incident
▢ Power Outage/Disruption of Utilities (External)
▢ Threats to Safety
▢ Staff, Contractor, or Stakeholder Criminal Activity
▢ Incident Involving Unidentified Child

▢ Code of Conduct Violation Not Involving a Child

▢ Unauthorized Photography, Video, or Surveillance
▢ Media Requests/External Questions
▢ IT Disruption/Internet Outage
▢ Natural Disaster or Weather Event

▢ Environmental
▢ Mechanical Malfunction
▢ Imminent Risk to Safety

▢ Maintenance
▢ Staffing Shortage

▢ Trespassing/Intruder
▢ Threats to Children or Staff
▢ Weapon Found

▢ Vehicle Accident
▢ Cyber Breech, Attack, or Threat

▢ Code of Conduct Violation

▢ Safety or Abuse/Neglect Concern

▢ Fraud
▢ Extortion
▢ Smuggling

▢ Failing to disclose staff misconduct
witnessed on or off duty

▢ Earthquake

▢ Trafficking
▢ Other Criminal Activity

▢ Failing to self-disclose misconduct
occurring on or off duty

▢ Wildfire

▢ Flood
▢ Tornado

▢ Records Issues

▢ Damaged Records
▢ Unauthorized Destruction of Records

▢ Death of an Adult or non-UAC Child
Incident Information

▢ Hurricane
▢ Storm

▢ Lost Records

Who initially reported the incident?*

Name

Type

A Number
Appears if user selects UAC

Title
Appears if user selects Staff

UAC
Staff
Non-UAC Child
Non-Staff Adult
Does the program need immediate guidance or resources? *
Were or are children being evacuated? *

 Yes  No

 Yes  No

Was or is the facility locked down or sheltered in place? *

 Yes  No

Has or will the program’s ability to provide healthcare services be affected? *

 Yes  No

Does the program have adequate resources to provide care for children for duration of the event? *
Did or will the event affect the program’s bed capacity? *
Specify Effect on Bed Capacity: *
Appears if user selects “Yes”
Describe the event and
explain the effect on the
program’s operations. *
Describe actions taken
to mitigate the impact
on children in care: *
ORR Recommendations:
*

Addendum

▢ Beds need to come offline

 Yes  No

▢ Unable to receive additional children

▢ Children need to be transferred to another program

 Yes  No

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

+

Updates, Follow-up, and/or Resolution (History)
Prior Text
Previously entered text is moved here upon save

Date Updated
System-generated

Submitted By
System-generated based on user

Updates, Follow-up,
and/or Resolution:

Immediate Phone Call Notifications:

Title

9-1-1
FFS Supervisor
Intakes Hotline
ICE FOJC

Name

Date Notified

202-401-5709

Reporting: (Additional fields for each section only appear when the use selects Yes for the first question)
State Licensing
Was it reported to State
Licensing? *
Was the event
investigated by State
Licensing?

 Yes  No

Date of Report:

Time of Report:

Yes
No
To Be Determined
Unknown

Date Notified the
Event will be
Investigated:

Case/Confirmation
Number:

Explain:
Disposition of
Investigation:

Results/Findings of
Investigation:
Attach
Reports/Findings:

Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed

Time Notified

CPS
Was it reported to CPS?
*

Was the event
investigated by CPS?

 Yes  No

Date of Report:

Time of Report:

Yes
No
To Be Determined
Unknown

Date Notified the
Event will be
Investigated:

Case/Confirmation
Number:

Explain:
Disposition of
Investigation:

Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed

Results/Findings of
Investigation:
Attach
Reports/Findings:

Law Enforcement
Was it reported to Law
Enforcement? *
Was the event
investigated by Local
Law Enforcement?

 Yes  No

Yes
No
To Be Determined
Unknown

Date of Report:

Time of Report:

Date Notified the
Event will be
Investigated:

Case/Confirmation
Number:

Explain:
Disposition of
Investigation:

Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed

Results/Findings of
Investigation:
Attach
Reports/Findings:

DCPI
Was it reported to
DCPI? *

Was the event
investigated by DCPI?

 Yes  No

Yes
No
To Be Determined
Unknown

Date of Report:

Time of Report:

Date Notified the
Event will be
Investigated:

Case/Confirmation
Number:

Explain:
Disposition of
Investigation:

Substantiated
Indicated
Not Substantiated
Unfounded
Administratively Closed

OIG
Was it reported to OIG?
*

 Yes  No

Date of Report:

Time of Report:

Explain:

DHS
Was it reported to DHS?
*

 Yes  No

Date of Report:

Time of Report:

Explain:

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

 Yes  No

Date of Report:

Time of Report:

Explain:

ORR Notifications

Title

Name

Date Notified

Time Notified

Method of
Notification

Specify

FFS Supervisor
Phone call
In-person
Email
Messaging app
Mail
Other
On-Call Field Staff

[email protected]

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 events affect the entire care provider facility. Public reporting burden for this collection of information is estimated to average 1.0 hour 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].