Form M-11I-UF Medical Coordinator Questionnaire

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OMB 0970-0564 [valid through MM/DD/2026]

(Revised: 3/16/2022)

Staff Questionnaire – Medical Staff – Unlicensed Facility (UF) Quarterly Health and Safety Visit

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. Questions in bold should be asked during the interview if possible. Other questions are optional prompts to assist the interviewer.

	NOTES
Tell me about your role and responsibilities as the program’s Medical Coordinator.
What are the things that you love/enjoy about your job? What are the challenges you face in your job?
Are you aware of ORR tools, such as the UC MAP, and where to find ORR policies and procedures and any updates? What is your system for adhering to policy and procedures, including updates, related to medical guidance? Describe any challenges the program has faced in successfully adhering to ORR policy/procedures/guidance regarding medical treatment.
Describe your system for tracking and documenting health and medical services.
Do you have opportunities for ongoing training and development? What additional trainings do you think the medical team could benefit from? Please describe how your agency addresses the additional training requirement on sexual abuse for medical and mental health practitioners. Is the specialized training helpful/sufficient? Do you have any suggestions for improvement? Is there any additional training that would be beneficial to better equip medical and mental health practitioners to respond to issues related to sexual abuse and/or sexual harassment?
Describe the procedures when there is an allegation of child abuse or maltreatment.
Do you have any concerns related to the confidentiality of medical information or services for UCs?
Describe how medical services are tailored for cultural sensitivity and age appropriateness.
What does trauma-informed care mean to you? How do you deliver trauma-informed care as part of the medical team?
How does the medical department work with the other program areas to ensure that the health needs of children are being met? How do staff (all shifts) receive important health information on each child regarding special conditions (i.e. disabilities, allergies, other relevant medical issues or medical emergencies)?
(If applicable) How do you accommodate a child with special health care needs or medication requirements?
What is the medical team’s policy/medical orders for youth with short-term injury or short-term contagious illness as it relates to participating in program activities? How do you ensure a child with a short-term injury or short-term contagious illness is excluded from participation in program activities when risk to the health or safety of that child or others is present? How does the medical team work to prevent youth from re-injuring or hurting themselves? What measures does the medical team take to prevent the spread of contagious illnesses?
How are written P&P established and maintained regarding medication administration, labeling, storage of all medications? What are the procedures for disposing of unused psychotropic medications? Describe how you track medication errors. Does the team use a specific system or documentation to track these errors? Can you provide an example?
What are the plans of action for health emergencies requiring rapid response? Are you aware of ORR policy that if there is an emergency SIR (hospitalization), the care provider must immediately notify the ORR Hotline by phone? (If coordinator does not mention this as a part of the response, ask specifically about this requirement and provide TA if needed.)
Describe your working relationship with outside medical stakeholders. Hospitals/mental health providers/outpatient medical clinics/dental care providers/etc. Are there any services youth need that the program does not have access to or has slow access to at this time?
Do you have any concerns about the treatment of UCs in care? Do you have any concerns about any particular staff members (any staff members you think should NOT be working with UC)?
Describe your working relationship with the program’s ORR medical coordinator.
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 contractor monitors to interview and document responses from medical coordinators during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 1 hour per response for the care provider and 1 hour per response for the 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.