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pdfOMB 0970-#### [Valid through MM/DD/20YY]
UAC Basic Information
First Name:
Last Name:
Date of Birth:
Photo of Minor
Status:
AKA:
Gender:
A No.:
Age:
Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:
Event Type: SIR Event
Date of
Event:
LOS:
LOC:
Current Program:
Current Location:
Time of
Event:
Event ID:
Synopsis of
Event:
Significant Incident Report
Emergency SIR
SIR
Emergency SIR
Death In Care Provider Facilty
---Select---
Medical Emergency Requiring Immediate Hospitalization
Other
Specify:
Incident Information:
Did the incident take place at
another care provider facility?
Yes
No Care Provider Name:
Care Provider City:
Location of
Incident:
Other Specify:
Care Provider State:
Date Reported To
Care Provider:
Date Reported To
ORR:
Time Reported To
Care Provider:
Time Reported To
ORR:
Description of Incident: (Full
Description of Incident)
Was the UAC or Anyone Else
Injured?:
Yes
No
Specify:
Actions Taken
Staff Response and Intervention
Follow-up and/or Resolution:
Recommendations:
Reporting:
Reported To State Licensing:
Yes
No
Was the Incident Investigated?
Yes
No
Date of
Report:
Date Notified the
Incident will be
investigated:
Time of
Report:
Case/Confirmation
Number:
Explain
Results/Findings of Investigation:
Attach Reports/Findings:
Is CPS Different From State
Licensing:
Yes
No
Reported To CPS:
Yes
No
Was the Incident Investigated?
Yes
No
Yes
No
Date of
Report:
Date Notified the
Incident will be
investigated:
Time of Report:
Case/Confirmation
Number:
Explain
Results/Findings of Investigation:
Attach Reports/Findings:
Reported To Local Law
Enforcement:
Date of
Report:
Time of Report:
Officer Name:
Officer Badge:
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 in which there
is an immediate threat to a child's safety and well-being that require instantaneous action. Public reporting burden for this collection of information is estimated to average 0.333 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. If you have any
comments on this collection of information please contact UACPolicy@acf.hhs.gov.
Was the Incident Investigated?
Yes
No
Date Notified the
Incident will be
investigated:
Case/Confirmation
Number:
Explain
Results/Findings of Investigation:
Attach Reports/Findings:
ORR Notifications:
Name
Agency/Title
Date Notified Time Notified
Telephone
Number
Email
ORR/FFS
ORR/PO
Medical
Coordinator
Case Coordinator
CFS
SIR Hotline
Other Notifications:
Is this an SIR for a Runaway?
Yes
No
Title
Name
Date Notified Time Notified
ICE Juvenile
Coordinator
Method of
Notification
Specify
Phone
Reporter and Follow-Up Contact:
Type
Staff Filing Report
Contact for Follow-Up
Name
Title
Email
Telephone Number
File Type | application/pdf |
File Modified | 2020-03-26 |
File Created | 2019-12-10 |