Form A-7 Notification of Concern

OMB 0970-0547 [valid through 05/31/2025]

Administration for Children & Families

Office of Refugee Resettlement

Notification of Concern

<Dropdown Menu>

“Original”, “Addendum”

Policies related to this form can be found in UC Policy Guide Section 6.

Released Child Information

Child Name A# [no spaces or dashes]

Age Date of Birth

Gender Country of Birth

Care Provider Name Date of Discharge

Date Reporting Party Informed of Event Reporter Name

Date of Report Submission Reporting Organization Type <Dropdown Menu>

“Care Provider”

“ORRNCC”

“PRS Provider”

Reporter E-mail Reporter Phone

Event Details

Location of Event <Dropdown Menu> Date of Event

"Care Provider Facility”

“Group Home”

“Foster Home”

“Community (field trip outside the foster home”

“Out-of-Network Placement”

“DHS Custody”

“Country of Origin”

“Journey to U.S.”

“U.S. interior (not in DHS or ORR custody)

Specify Location if Event Occurred:

at Care Provider <Dropdown Menu>

“Dining Facility”

“Dormitory Area”

“Field Trip”

“Medical Facility”

“Off-site Appointment”

“Recreational Area”

“Restroom or Shower”

“School Area”

“Other”

in DHS Custody <Dropdown Menu>

“CBP Custody”

“ICE Custody”

“Unknown”

Synopsis of Event

Sponsor Information

Sponsor Name Sponsor Category<Dropdown Menu>

“Category 1”

“Category 2A”

“Category 2B”

“Category 3”

Relationship to Child Address

City State <Dropdown Menu> (All States)

Zip Code Reporter Entered/ Will Enter Sponsor Flag? <dropdown menu>

“Yes”, “No”

Reporter Entered/ Will Enter Sponsor Address Flag? <Dropdown Menu> “Yes”, “No”

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR grantees to notify ORR of situations reported after a child is released from ORR custody that affect the child's safety and well-being. Public reporting burden for this collection of information is estimated to average 0.33 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.

Primary Caregiver Information

If the child is living with someone other than the sponsor, (i.e. the “primary” or “alternate caregiver”), please provide as much information as you can; if unknown, leave field blank.

Caregiver Name Address

City State <Dropdown Menu> (All States)

Zip Code

Incident Information

Definitions for sexual abuse, sexual harassment, and staff code of conduct and boundary violations can be found in UC Policy Guide Section 4.

Notification of Concern Category (select all that apply)

• Abuse/Neglect

  • Verbal or Emotional Abuse

  • Domestic Violence

  • Physical Abuse

  • Sex Trafficking Concerns

  • Labor Trafficking Concerns

  • Neglect or Abandonment

  • Unknown

• Sexual Abuse of Minor by Minor

  • Intentional touching, directly or through clothing, of another's genitalia, anus, groin, breast, inner thigh, or buttocks

  • Penetration of another child's anal, oral, or genital area by a body part or object

  • Forcing another child to touch/penetrate genitalia, anus, groin, breast, inner thigh, or the buttocks of another child

  • Exposure of buttocks, breast, or genitalia of self or another person (excluding unintentional, incidental exposure such as in a bathroom)

  • Knowingly masturbating in another person's presence

  • Bestiality

  • Sadistic or masochistic abuse

  • Possession or use of child pornography

  • Child prostitution

• Sexual Abuse of Minor by Adult

  • Actual or simulated sexual intercourse

  • Molestation (penetration or touching unrelated to official job duties of another child's buttocks, breasts, or anal, oral, or genital area by a body part or object)

  • Prostitution of a child

  • Forcing a child to engage in sexual exploitation of another child

  • Any display of staff's uncovered buttocks, breast, or genitalia in the presence of a child

  • Masturbation

  • Bestiality

  • Sadistic or masochistic abuse

  • Possession or use of child or adult pornography

  • Voyeurism

  • Any attempt, threat, or request to engage in any of the activities above

• Sexual Harassment

  • Repeated and unwelcome sexual advances or requests for sexual favors

  • Repeated verbal comments, gestures, phone calls, and/or all electronic communication that are derogatory or sexual in nature

  • Repeated actions of a derogatory or offensive sexual nature

• Inappropriate Sexual Behavior

• Staff Code of Conduct & Boundary Violation ("staff" refers to care provider facility staff)

• Failing to confine relationships with unaccompanied children, families and sponsors to within scope of duties

• Cohabitating with a child before the child turns 21 years old

• Having any contact with any child outside of the care provider facility beyond scope of duties while the child is in ORR care or before the child turns 21 years old

• Engaging in a romantic relationship with a child while the child is in ORR care or before the child turns 21 years old

• Providing letters, gifts, pictures, or any personal contact/ social media information with any child in ORR care or before the child turns 21 years old

• Failing to confine relationships with the child’s family and/or sponsor to within scope of duties

• Failure to report any knowledge, suspicion, or information about sexual abuse, sexual harassment, or inappropriate sexual behavior

• Child Behavioral Incident with Safety Concerns/ Risk for Self or Others in Home Community. (Note: this refers to the child’s actions, not actions of others towards the child)

• CPS Involvement

  • ^{CPS Active Case}

  • CPS Removal

  • CPS Reported to ORRNCC

  • NOC reporter initiated concurrent CPS reporting

• Criminal Activity or Charges against Released Child

• Criminal Activity or Charges against Sponsor that Directly Affect Child Safety

• Death of Released Child (Alert: Notify ORR Immediately)

• Media Attention

• Placement Disruption with Safety Concerns

• Fraud

  • Actual or Potential Fraud Scheme Targeting Sponsor or Child

  • Intentional Information and/or Document Fraud

• Serious Medical and/ or Mental Healthcare Issue or Unplanned Hospitalization

  • Pregnancy with Complications

  • Emergency (Alert: Notify ORR Immediately)

• Substance Use that Requires Additional Support/Services

• Location of Released Child Unknown with Safety Concerns

  • ^{Known Runaway}

  • Known Child Abduction

  • Unknown

• Other Sponsor-Related Concerns:

  • Lost Contact with Sponsor and/or Released Child with Safety Concerns (Note: loss of contact alone is not a safety concern)

  • Unable to Establish Contact with the Sponsor or Released Child within 30 Days of Release or Referral Acceptance

Alleged Perpetrator <Dropdown Menu”

“Program Staff”

“UC or Released Child”

“Other Child”

“Non-Staff Adult”

“Other”

How was this child involved? <Dropdown Menu>

“Victim”

“Alleged Perpetrator”

“Witness”

“Reporter”

“Other”

Summary of Incident

Case Worker Response and Intervention

Persons/Agencies Contacted

Use the +/- buttons to add or delete rows. Please add a row for each unique contact. Do not delete previous entries unless entered in error.

	Agency or Person (Title)	Type of Agency	Date Reported	Case Number	State	Phone Number
+ -		<Dropdown Menu> “Local Law Enforcement” “CPS” “NCMEC” “Residential Staff” “Other”			<Dropdown Menu> (All States)

Addendums

Use the +/- buttons to add or delete rows. Do not delete previous addendums unless entered in error.

	Addendum Date	Addendum Description
+ -

A-7 | Version 2

MM/DD/YYYY

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