Form A-9A Child-Level Event

Child-Level Event (Form A-9A)

Please see UC Policy Guide Sections 4 and 5 for related policies.

• Current Care Provider Facility
• Previous Care Provider Facility
• Group Home
• Foster Home
• Community (field trip or outside the foster
home)
• Out-of-Network Placement
• DHS Custody
• Country of Origin
• Journey to U.S.
• U.S. Interior, not DHS or ORR
Appears if "Current Care Provider Facility,"
"Previous Care Provider Facility," "Group
Home," or "Foster Home" selected for
Location of Event. Dropdown includes all
care provider programs.

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 document events occurring in and outside of ORR care that must be reported to ORR. Public reporting burden for this collection of information is estimated to
average 0.17 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. The OMB control
number is 0970-0547 and the expiration date is 5/31/2025. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov.

NOTE: Date of Event and Time of Event appear if “Current Care Provider Facility,“ “Previous Care
Provider Facility,” “Group Home,“ “Foster Home,“ “Community (field trip or outside the foster home),“
or “Out-of-Network Placement“ selected for Location of Event.
Approximate Date of Event Month/Year appears if “DHS Custody,“ “Country of Origin,“ “Journey to
U.S.,“ or “U.S. Interior, not DHS or ORR“ selected for Location of Event (see screenshot on page 2)

Appears if "Current Care Provider Facility,"
"Previous Care Provider Facility," "Group
Home," or "Foster Home" selected for
Location of Event. Dropdown options:
• Dining Facility
• Dormitory Area
• Field Trip
• Medical Facility
• Off-site Appointment
• Recreational Area
• Restroom or Shower
• School Area
• Other
Appears if "DHS Custody" selected for
Location of Event. Dropdown options:
• CBP Custody
• ICE Custody
• Unknown

Please see UC Policy Guide Sections 4 and 5 for related policies.

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 document events occurring in and outside of ORR care that must be reported to ORR. Public reporting burden for this collection of information is estimated to
average 0.17 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. The OMB control
number is 0970-0547 and the expiration date is 5/31/2025. If you have any comments on this collection of information please contact UCPolicy@acf.hhs.gov.