Form A-10C Significant Incident Report

OMB 0970-0547 [Valid through MM/DD/YYYY]

 Abuse/Neglect in ORR Care

Type of Abuse: ---Select---

 Past Abuse/Neglect Not in ORR Care

 Abuse in Home Country

 Abuse On Journey

 Neglect/Abandonment in Home Country

 Neglect/Abandonment in the United States

 Abuse in United States

 Other

 Abuse in DHS Custody

Specify:



Alleged Perpetrator: ---Select---



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 situations that affect, but do not 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 UCPolicy@acf.hhs.gov.

 Physical Abuse in ICE Custody
 Sexual Abuse in ICE Custody
 Physcial Abuse in CBP Custody
 Sexual Abuse in CBP Custody
 Other
Specify:
 Behavioral Incidents that do not threaten
immediate safety

 Possession of a Weapon

 Physical Aggression

 Suicidal Ideation

 Use of Drugs and/or Alcohol in ORR Custody

 Verbal Aggression

 Self-Harm without medical intervention

 Destruction of Property

 Past Self-Harm

 Other

 Past Suicide Attempt/Gesture

Specify:
 Incidents Involving Law Enforcement

 Search

 Investigate/Response

 Interview

 Arrest

 Other
Specify:
 Safety Measures

 One-on-One Supervision

 Use of Restraints

 Criminal History

 Significant Criminal History in Home Country

 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:

 Potential Fraud Schemes

 Confidence Scheme

 Document/Information Fraud

 Other

 Contact or Threats to UC while in ORR Care (from smuggling syndicates, organized crime, other criminal actors)
 Separated from Parent/Legal Guardian
 Previous Enrollment in DHS Migrant Protection Protocols Program
 Other

Specify: