Form A-12 Hotline Alert

OMB 0970-#### [Valid through MM/DD/20YY]
Hotline Alert

Incident Information
Incident Information
Description of Incident:

Date of Incident:
Were staff present or involved in the incident?
If Yes, Explain:

Was this incident reported to the program or anyone else?
If Yes, Explain:
Date Reported:
Program Information
Program Where Incident
Occurred:
Program City:
Program State:
Other Description:
UAC Information
First Name:
Last Name:
A-Number:
Gender:
Age:
Country of Birth:
Other Description:
Were Other UAC Involved?:
If Yes, Explain

Reporting
Type of Incident/Individuals Involved
Type of Incident:

  Specify: 

Type of Allegation:
Synopsis of call:

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR's National Call Center to inform ORR of allegations sexual harassment,
sexual abuse, inappropriate sexual behavior, and physical abuse that occurred while the UAC was in ORR custody. 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.

Hotline Reporting
Reported to CPS:
State 1:

State 2:

State 3:

Date of Report 1:
Time of Report 1:

Date of Report 2:
Time of Report 2:

Date of Report 3:
Time of Report 3:

Case Number 1:

Case Number 2:

Case Number 3:

State 1:

State 2:

State 3:

Date of Report 1:
Time of Report 1:

Date of Report 2:
Time of Report 2:

Date of Report 3:
Time of Report 3:

Case Number 1:
Officer Name 1:

Case Number 2:
Officer Name 2:

Case Number 3:
Officer Name 3:

Officer Badge
Number 1:

Officer Badge
Number 2:

Officer Badge
Number 3:

Reported to Law
Enforcement:

Date Incident Reported to
ORR:
Time Incident Reported to
ORR:

ORR Reporting
Not enough information to identify a UAC or care provider No
Role
FFS
FFS
Supervisor
PO
Comments:

Name

Email

Date Notified

Time Notified