Form M-9 Form M-9 Foster Home On Site Monitoring Checklist

Updated: 11/19/19 OMB 0970-#### [valid through MM/DD/YYYY]

Foster Home Monitoring Checklist – Walkthrough (LTFC and TFC)

General Home Information
Foster Parent Name(s):	Name of UAC:	Foster Home Licensed Capacity:
Foster Home Address:	Date of Home Visit:	# of Children in Foster Home:	Age/Gender:
Program Name:	Type of Foster Home License:	# of Adults in Foster Home:	Relationship to FP/Gender:

*** PLEASE NOTE ANY NEW/UNKNOWN NAMES, AGES, RELATIONSHIPS, and MEDICAL NEEDS of Adults or Children living or working in the home (verify all info with FP case file)***

	Compliant?				Compliant?
General Safety and Security	Y	N	n/a		Y	N	n/a
Cleaning chemicals inaccessible to UAC				Firearms (if applicable) inaccessible to UAC
Medical supplies/prescriptions inaccessible to UAC				Other unsafe areas inaccessible to UAC
Fire extinguishers and smoke alarms in working order (test)				Pets? (clean/dangerous)
Playground/outdoor equipment (if applicable) appears safe and age appropriate				Outdoor area secure (fences in good repair, pool, supervised access)
Carbon Monoxide detectors (if applicable, gas fuel in home)

1. General Safety and Security

	Compliant?				Compliant?
Confidentiality	Y	N	n/a		Y	N	n/a
Confidential UAC information in a secure location				Case files being maintained indefinitely by program
Only individuals with a need to know basis have access to the case files				Case files safe from physical damage
Private place for UAC to make phone calls (if applicable)				Telephones/Cell Phones available for UAC to make PREA related calls (best practice)

2. Confidentiality

	Compliant?				Compliant?
General Home Structure	Y	N	n/a		Y	N	n/a
Clean and Safe (windows/door locks)				Kitchen
Child-friendly (e.g. no safety/trip hazards)				UAC dietary restrictions posted/accessible
Home is properly maintained (including furniture)				Food stored in a sanitary manner
Infants/toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)				Knives/sharp objects inaccessible to youth
Well-ventilated
Adequately heated/cooled				Bathrooms
Child-to-parent ratio met				Soap
				Toilet paper
Bedrooms				Working toilets
Separate by gender (per state licensing)				Hot/cold water
Natural light/dark at night				Appropriate privacy
Private place to store personal items/clothing				Hygiene/grooming items
UAC provided appropriate clothing/footwear				Towels
Provision of appropriate linens
Adequately accommodate all UAC

3. General Home Structure

	Compliant?				Compliant?
Documents that should be accessible to youth	Y	N	n/a		Y	N	n/a
Phone numbers for UAC to report sexual abuse/harassment (best practice)				Grievance procedures posted
Program rules posted				Extra copies of UAC grievance forms
Foster home rules				Evacuation procedures posted prominently on each floor

4. Documents that should be accessible to youth

Foster Home Monitoring Checklist – Other

	Observed?				Observed?
Services to Potentially Observe	Y	N	n/a		Y	N	n/a
Recreation – large muscle, outdoors				Chore assignments
Meals

			Reviewed?
Logs/Schedules to Potentially Review			Y	N	n/a
UAC documents maintained by the foster parent (phone logs, prescription logs, recreation logs/calendar, fire drill logs etc.)

Other Notes

THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR Monitoring Team staff to document their findings during the walkthrough portion of biennial site visits. Public reporting burden for this collection of information is estimated to average 0.5 hours per response (if the site visit is performed by a contractor monitor), 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.