Form A-10C Significant Incident Report

OMB 0970-#### [Valid through MM/DD/20YY]
UAC Basic Information

First Name:
Last Name:
Date of Birth:
A No.:
Age:

Photo of Minor

Status:
AKA:
Gender:
LOS:
LOC:

Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:

Current Program:
Current Location:

Event Type: SIR Event
Date of
Event:

Time of
Event:

Event ID:

Synopsis of
Event:
Significant Incident Report

Emergency SIR

SIR
SIR

Abuse/Neglect in ORR Care
Past Abuse/Neglect Not in
ORR Care

Alleged Perpetrator:

---Select--Abuse In Home Country
Neglect/Abandonment in the Home Country
Abuse In UnitedStates
Abuse In DHS Custody

---Select---

Abuse On Journey
Neglect/Abandonment in the United States
Other
Specify: 

Physical Abuse In ICE Custody
Sexual Abuse In ICE Custody
Physical Abuse In CBP Custody
Sexual Abuse In CBP Custody
Other
Specify: 
Major Behavioral Incidents
that threaten safety

Possession/Use of a Weapon

Physical Aggression/Harm to Others

Suicidal Ideation
Verbal Aggression
Other

Use of Drugs and/or Alcohol in ORR Custody
Self-injurious Behaviors/Self Mutilation
Suicide Attempt/Gesture

Specify: 
Runaway
Incidents Involving Law
Enforcement

Runaway

Attempted Runaway

Search
Interview

Investigate/Response
Arrest

Other
Specify: 
Safety Measures

One-on-One Supervision

Criminal History

Significant Criminal History in Home Country

Use of Restraints

Pat-Down or Other Searches

Significant Criminal History in United States
Other
Specify: 
Pregnancy Related Issues

Pregnancy

Childbirth

Termination Request

Please describe how the pregnancy occurred and if there are any medical complications related to the
pregnancy:
Other

Contact or Threats to UC while in ORR Care (from smuggling syndicates, organized crime, other criminal
actors)
Separated from Parent/Legal Guardian
Other
Specify: 
Incident Information:

Did the incident take place at
another care provider facility?
Location of

Yes

No Care Provider Name:
Care Provider City:
Date Reported To

-- Select Provider Name --- Select Provider City -- Care Provider State: -- Select Provider State -Time Reported To

THE PAPERWORK REDUCTION
ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLICCare Provider:
BURDEN: The purpose of this information collection is to allow ORR
care provider programs to inform ORR of situations that affect, but do not
Incident:
Care Provider:
immediately threaten, the safety and well-being of a child. 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.

Date Reported To
ORR:

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:

Time of
Report:

Date Notified the
Incident will be
investigated:

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:

Was the Incident Investigated?

Yes

No

Date of
Report:

Time of Report:

Officer Name:

Officer Badge:

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