Form M-11C Clinician Questionnaire

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OMB 0970-0564 [valid through MM/DD/2024]

(Revised: 5/15/2020)

Staff Questionnaire – Clinician/Lead Clinician

Interview Details
Program Name:	Past and Current Position(s) at Program:
Level of Care:	Date/Time of Interview:
Full Name:	Interviewer:

*Note: Before beginning the interview and/or providing this questionnaire to staff, provide a brief introduction, including monitor role and purpose of monitoring visit, confidentiality of staff interview, and clarify any questions. See Introduction Prompt for Staff for additional guidance as needed.

	NOTES
Tell me about your role and main responsibilities as a clinician.
Tell me about your educational background and how you ended up working as a clinician here. Are you licensed? (If not licensed, explain your current licensure status.)
What is your typical caseload? What would be the ideal manageable caseload?
Do you have any concerns related to the confidentiality of mental health services? (i.e. designated confidential space, confidential record management system) If so, please describe.
What approach do you implement in providing individual and group counseling sessions for UACs? Can you describe how your model or approach is trauma-informed? Describe how you successfully implement mental health and crisis-related interventions with UACs. Explain your process for tracking progress in a child’s case. Describe how mental health services are tailored for cultural sensitivity and age appropriateness. Do you utilize any assessment or screening tools in addition to ORR required assessments?
What does trauma-informed care mean to you? How do you deliver trauma-informed care as part of the clinical team?
What are the things that you love/enjoy about your job? What are the challenges you face in your job?
What system do you use to track and document clinical sessions? What do you primarily use the UAC Portal for? (i.e. risk assessment, ISP, etc.)
What formal/informal trainings have you received since working here? What additional trainings do you think the clinical team could benefit from? What did you think about the additional training on sexual abuse for medical and mental health practitioners? (i.e. helpful, sufficient, any suggestions for improvement, etc.) (Lead Clinician) Do you have a system to assess ongoing staff training needs? Please describe any training needs that your staff currently has.
How does the program handle behavioral challenges among UACs? How effective do you think the behavior management system is?
Do you have any concerns about the treatment of UACs in care? Do you have concerns about any particular staff members (any staff members you think should NOT be working with UAC)?
If a UAC in care is presenting with mental health concerns that warrant additional services, how does the program respond?
How does the clinical team collaborate and communicate with other departments? How are minors given appropriate accommodations for special mental health concerns or needs? What recommendations do you have to strengthen the collaboration and communication with other departments? How are you notified if other staff have a concern about a minor’s mental health needs?
What is the program’s plan for dealing with a mental health emergency? Have you had a mental health emergency at the program since you began working here? If so, please describe the situation.
Please describe your relationship with your supervisor. How often do you have individual and/or group supervision? How often do you participate in other staff meetings? Do you feel that you have adequate support from you supervisor?
(Lead Clinician) Do you have enough input and resources to make changes to improve mental health services at the program? Do you think the current system is effective for meeting the mental health needs of UACs in care? What are the strengths and things that could be improved to the current system? How do you help your assigned clinicians deal with secondary UAC trauma exposure and the other stressors of the clinician job? (Reflective Supervision?)
What general recommendations do you have to strengthen the program? What improvements would you put in place? Have you shared these ideas with your supervisor or any other program staff?
What recommendations do you have for ORR that I can take back to share with our headquarter teams?

Additional Notes

Enter Additional 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 interview and document responses from clinicians and lead clinicians during biennial site visits. Public reporting burden for this collection of information is estimated to average 1.0 hour per response (plus an additional 1.0 hour 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 UCPolicy@acf.hhs.gov.