Form A-10D Significant Incident Report Addendum

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

First Name:

Photo of Minor

Status:

Last Name:
Date of Birth:
A No.:
Age:
Child’s Country of
Birth:
Admitted Date:
ORR Placement
Date:
Event Type: SIR Event
Date of
Event:

AKA:
Gender:
LOS:
LOC:
Current Program:
Current Location:

Time of
Event:

Event ID:

Synopsis of
Event:
Significant Incident Report   (Addendum)

Emergency SIR

SIR
SIR

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

Alleged Perpetrator:

---Select---

---Select---

Abuse In Home Country

Abuse On Journey

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

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
Suicidal Ideation
Verbal Aggression

Physical Aggression/Harm to Others
Use of Drugs and/or Alcohol in ORR Custody
Self-injurious Behaviors/Self Mutilation

Other

Suicide Attempt/Gesture

Specify: 
Runaway
Incidents Involving Law
Enforcement

Runaway

Attempted Runaway

Search

Investigate/Response

Interview
Other

Arrest

Specify: 
Safety Measures

One-on-One Supervision

Criminal History

Significant Criminal History in Home Country
Significant Criminal History in United States
Other

Use of Restraints

Pat-Down or Other Searches

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
Incident:

Yes

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

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

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 provide additional information obtained after
a Significant Incident Report has been submitted to ORR. Public reporting burden for this collection of information is estimated to average 0.25 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 (History)

Description of Incident: (Full
Description of Incident)
Was the UAC or Anyone Else
Injured?:

Yes

No

Specify:
Actions Taken
  Staff Response and Intervention (History)

Staff Response and Intervention
  Follow-up and/or Resolution (History)

Follow-up and/or Resolution:
  Recommendations (History)

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
  Progress of Investigation (History)
  Results/Findings of Investigation (History):

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
  Progress of Investigation (History)
  Results/Findings of Investigation (History):

Results/Findings of Investigation:
Attach Reports/Findings:
ORR Notifications:

Name

Agency/Title

Date Notified Time Notified

Telephone
Number

Email

ORR/PO
Medical
Coordinator
Case Coordinator
CFS
SIR Hotline
ORR/FFS
Other Notifications:

Is this an SIR for a Runaway?

Yes

No

Title
ICE Juvenile
Coordinator

Name

Date Notified Time Notified

Method of
Notification
Phone

Specify

Reporter and Follow-Up Contact:

Type
Staff Filing Report
Contact for Follow-Up

1

Name

Title

Email

Telephone Number