Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping

Monitoring and Compliance for Office of Refugee Resettlement (ORR) Care Provider Facilities

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Document Name Document Type
Form Form M-11A-UF Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping Form and Instruction
Form M-11A-UF Program Director Questionnaire 3 - Program Director Questionnaire (Form M-11A-UF).docx Form and Instruction
Form M-11C-UF Clinician Questionnaire 4 - Clinician Questionnaire (Form M-11C-UF).docx Form and Instruction
Form M-11E-UF Case Manager Questionnaire 5 - Case Manager Questionnaire (Form M-11E-UF).docx Form and Instruction
Form M-11G-UF Education Staff Questionnaire 6 - Education Staff Questionnaire (Form M-11G-UF).docx Form and Instruction
Form M-11I-UF Medical Coordinator Questionnaire 7 - Medical Coordinator Questionnaire (Form M-11I-UF).docx Form and Instruction
Form M-11J-UF Youth Care Worker Questionnaire 8 - Youth Care Worker Questionnaire (Form M-11J-UF).docx Form and Instruction
Form M-11K-UF PSA Compliance Manager Questionnaire 9 - PSA Compliance Manager Questionnaire (Form M-11K-UF).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Unlicensed Facility Program Staff Questionnaires (Forms M-11A-UF to M-11K-UF) - Recordkeeping	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-11A-UF	Program Director Questionnaire	3 - Program Director Questionnaire (Form M-11A-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11C-UF	Clinician Questionnaire	4 - Clinician Questionnaire (Form M-11C-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11E-UF	Case Manager Questionnaire	5 - Case Manager Questionnaire (Form M-11E-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11G-UF	Education Staff Questionnaire	6 - Education Staff Questionnaire (Form M-11G-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11I-UF	Medical Coordinator Questionnaire	7 - Medical Coordinator Questionnaire (Form M-11I-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11J-UF	Youth Care Worker Questionnaire	8 - Youth Care Worker Questionnaire (Form M-11J-UF).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11K-UF	PSA Compliance Manager Questionnaire	9 - PSA Compliance Manager Questionnaire (Form M-11K-UF).docx	Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 18	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	1,800	1,800
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.