Form A-9B Emergency Significant Incident Report - UC Path Version

Emergency Significant Incident Report and Addendum (Form A-10A)
Data Entry Window
OMB 0970-0547 [valid through MM/DD/YYYY]

Other

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 1.5 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.
UAC-A-10A [Rev. MM/DD/YYYY]

Emergency Serious Incident Report Page
Editable page created after Save is clicked in the data entry window.

OMB 0970-0547 [valid through MM/DD/YYYY]
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 1.5 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.
UAC-A-10A [Rev. MM/DD/YYYY]

Collaborators Data Entry Windows
New feature that allows case manager or ORR staff to give read/write access to other users. Restricted to granting
access to individuals inside their organization or to ORR staff.

Individuals Involved in Incident Data Entry Window
New feature that allows case managers to link profiles of care provider staff or UAC that are already in the system to the
SIR.

SIR Notifications Data Entry Window
Allows case managers to manually add an individual to whom they are reporting the SIR. ORR staff members assigned to
the care provider are pre-populated in the table and do not need to be added manually. This replaces the following
tables in the current version of the SIR: ORR Notifications, Other Notifications, and Reporter and Follow-up Contact.

Addendum Data Entry Window
Case managers complete the two fields below and then make edits or add information to the SIR.

Documents Data Entry Window
New feature that allows documents to be attached directly to the SIR.

Send SIR/PLE Email
Case managers use the in-system email to send a copy of the SIR to parties who are required to be notified. Email
addresses auto-populate from the SIR Notifications table. The email subject line and information in the body of the
email are also auto-populated.

System-Generated PDF