UAC Basic Information First Name: John Daniel Status: ADMITTED Last Name: Doe Jones AKA: Date of Birth: 11/30/2002 Gender: M A No.: 123456789 LOS: 33 Age: 16 LOC: 148 Child's Country of Birth: Africa Current Program: Test Program 1 Admitted Date: 9/18/2019 Current Location: Houston, TX ORR Placement Date: 5/25/2019 Event Type: SIR Event Date of Event: 4/1/2019 Time of Event: 12:00 PM Event ID: 123456 Synopsis of Event: During the mental health screening process, client disclosed living alone since he was fifteen years old in COO of Africa. Significant Incident Report (Addendum) Emergency SIR SIR SIR Abuse/Neglect in ORR Care ---Select--- Alleged Perpetrator: ---Select--- Past Abuse/Neglect Not in ORR Care Abuse In Home Country Neglect/Abandonment in the Home Country Abuse In UnitedStates Abuse In DHS Custody Abuse On Journey Neglect/Abandonment in the United States Other Specify: Physical Abuse In ICE Custody Sexual Abuse In ICE Custody Physical Abuse In CBP Custody Sexual Abuse In CBP Custody Other Specify: Major Behavioral Incidents that threaten safety Possession/Use of a Weapon Suicidal Ideation Verbal Aggression Other Physical Aggression/Harm to Others Use of Drugs and/or Alcohol in ORR Custody Self-injurious Behaviors/Self Mutilation Suicide Attempt/Gesture Specify: Runaway Runaway Attempted Runaway Incidents Involving Law Enforcement Search Interview Other Investigate/Response Arrest Specify: Safety Measures One-on-One Supervision Use of Restraints Pat-Down or Other Searches Criminal History Significant Criminal History in Home Country 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: Other Contact or Threats to UC while in ORR Care (from smuggling syndicates, organized crime, other criminal actors) Separated from Parent/Legal Guardian Other Specify: Incident Information: Did the incident take place at another care provider facility? Yes No Care Provider Name: -- Select Provider Name -- Care Provider City: -- Select Provider City -- Care Provider State: -- Select Provider State -- Location of Incident: Other Date Reported To Care Provider: 9/22/2019 Time Reported To Care Provider: 12:00 PM Other Specify: Afriaca Date Reported To ORR: 9/22/2019 Time Reported To ORR: 12:00 PM Description of Incident (History) Prior Text Date Updated Submitted By This is a sample for training and experimenting purposes only. 10/21/2019 4:36:28 PM joe.test@tyu.org Description of Incident: (Full Description of Incident) This is a sample for training and experimenting purposes only. Was the UAC or Anyone Else Injured?: Yes No Specify: N/A Actions Taken Staff Response and Intervention (History) Staff Response and Intervention This is a sample for training and experimenting purposes only. Follow-up and/or Resolution (History) Follow-up and/or Resolution: This is a sample for training and experimenting purposes only. Recommendations (History) Recommendations: This is a sample for training and experimenting purposes only. Reporting: Reported To State Licensing: Yes No Date of Report: Time of Report: Was the Incident Investigated? Yes No Date Notified the Incident will be investigated: Case/Confirmation Number: Explain Progress of Investigation (History) Results/Findings of Investigation (History): Results/Findings of Investigation: Attach Reports/Findings: