OMB 0970-0564 [valid through MM/DD/2026]
Unlicensed Facility Quarterly Health and Safety Monitoring Checklist – Facility Walkthrough
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Controlled entry/exit of premises |
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Knives/sharp objects inaccessible to UC |
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Prohibited from allowing entry of any individual (except UC in the process of admission) who meet any COVID-19 criteria |
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Cleaning chemicals maintained in a locked area |
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Alarms system for all areas of the residential structure |
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Medical supplies/prescriptions inaccessible to UC |
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Video monitoring in common and living areas and classrooms |
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Other unsafe areas inaccessible to UC |
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Video monitoring for exterior of building & surrounding premises |
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Vehicle(s) inspection stickers up-to-date |
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Ability to download video footage permanently |
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Vehicle(s) appear to be in good repair (including fire extinguisher and first aid kit) |
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System for tracking and regulating UC movement |
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Vehicle (s) contain working seat belts |
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Meeting UC to floor staff ratios/appropriate supervision |
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Evacuation procedures posted prominently on each floor and at eye level for children and youth |
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“Mirrored windows”/window in offices where staff meet with child 1:1 |
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Fire extinguishers and smoke detectors in good working order and inspected (as required) |
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Infants/Toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers) |
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Play equipment safe and in good repair |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Case files in secure location (open and closed) |
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Case files safe from physical damage |
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Only individuals with a need to know basis have access to the case files |
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Pre-programmed telephones (Required: UC SA Hotline, CPS, Local Community Service Provider; Highly recommended: Top 3 consulates and LSP) |
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Private place for UC to make phone calls (including pre-programmed phones) |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Clean |
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Kitchen |
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Child-friendly (e.g. no safety/trip hazards) |
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UC dietary restrictions posted/accessible |
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Furniture and building are properly maintained |
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Food stored in a sanitary manner |
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Well-ventilated |
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Bathrooms |
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Adequately heated/cooled |
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Soap |
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Identified UC Medical Quarantine/Isolation Space |
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Toilet paper |
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Bedrooms |
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Working toilets |
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Natural light/Dark at night |
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Hot/cold water |
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Provision of appropriate linens |
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Separated by gender |
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Adequately accommodate all UC (per State Licensing) |
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Appropriate privacy |
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Separated by gender (per licensing) |
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Hygiene/grooming items |
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Adequately accommodate all youth (e.g. individual bed with mattress for each youth) |
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Towels |
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Provision of appropriate bed linens |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
Posters with phone numbers for UC to report sexual abuse/harassment |
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Care Provider AND ORR Pamphlets on sexual abuse/harassment |
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Notice to Pregnant Females (Garza vs. Azar) next to posters |
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Extra copies of UC grievance forms |
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Grievance Procedures (in common areas) |
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Program Rules |
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Saravia Notice (English and Spanish posted next to Garza and Sexual Abuse/Harassment notices) – posting currently applicable to Secure, Staff Secure and RTC – effective 10/22/2020 |
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Compliant? |
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Compliant? |
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Y |
N |
n/a |
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Y |
N |
n/a |
UC/Staff provided/wearing face masks and/or offered face masks, as applicable |
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Emergency Evacuations Notification List (must be posted in office area and includes: ORR contacts, DHS contact, and local law enforcement) |
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Car Seats (if transporting young children) |
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No Touch Thermometers available |
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Sufficient supply of Face Mask / Hand Sanitizers / Gloves |
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Walkthrough NOTES
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On-Site Monitoring Checklist - Other
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Observed? |
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Observed? |
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Services to Potentially Observe |
Y |
N |
n/a |
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Y |
N |
n/a |
Education |
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Group counseling/community meeting |
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Recreation – large muscle, outdoors |
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Meals |
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Reviewed? |
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Reviewed? |
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Logs/Schedules to Potentially Review |
Y |
N |
n/a |
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Y |
N |
n/a |
Fire Drills Logs |
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Grievance binder |
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Daily (Shift) logs |
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Group Counseling Curriculum |
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System for inspecting vehicles |
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Visitor Logs |
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Prescription/Non-prescription medication logs |
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Care Provider Policies for UC to Request Emergency and Non-Emergency Health Care Services |
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Spot Inspections and Quarterly Safety Assessments |
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UC Temperature Tracker |
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Facility inspection checklist (safety check) |
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Other NOTES
Services to Observe |
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Logs to Review |
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THE
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF
PUBLIC BURDEN: The purpose of this information collection is to
allow ORR contractor monitors to document their findings during the
walkthrough portion of unlicensed facility quarterly site visits.
Public reporting burden for this collection of information is
estimated to average 4 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
UACPolicy@acf.hhs.gov.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
File Modified | 0000-00-00 |
File Created | 2023-12-13 |