Form M-11J-UF Youth Care Worker Questionnaire

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

(Revised: 3/16/2022)

Staff Questionnaire - Youth Care Worker/Lead Youth Care Worker – 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 main responsibilities as a Youth Care Worker.
What are the things that you love/enjoy about your job? What are the challenges you face in your job?
What formal/informal trainings have you received? What additional training do you think a person in your position could benefit from? (Lead Youth Care Worker) Do you have a system to assess ongoing staff training needs? Please describe any training needs that your staff currently have.
Tell me about how you usually handle behavioral challenges among UCs? How effective do you think the behavior management system is? Have you received trainings on Behavior Management? If yes, what did you learn in the training? Are you allowed to use restraints? Please elaborate.
What does trauma-informed care mean to you? How do you deliver trauma-informed care as part of the YCW team?
How do you usually handle mental health concerns among UCs in the program? With whom would you talk to and how would you respond to the concern? Do you feel confident in your ability to appropriately handle a mental health emergency or crisis situation?
What are the required UC to staff ratios? Daytime: Evenings During transportation:
What does line of sight supervision mean to you? How do you ensure line of sight supervision during the following periods? Daytime: Nighttime: Weekends: During transportation: Legal Orientation:
What activities are provided to UC every day? Outdoor: Indoor: Weekends:
How often are youth required to be outside? Weekdays: Weekends:
When YCWs come on shift, how are updates/lingering issues communicated between shifts? How are YCWs informed about the following: UAC with special conditions: Disabilities: Allergies:
Describe the procedures for the following situations: (Please note: any/multiple example(s) can be used for this question) An allegation of child abuse or maltreatment: (Example: UC reports that a staff has made sexually inappropriate comments to youth) Runaway: Fire drill: Grievances:
What are some of the topics covered by the Code of Conduct? What happens if you violate the Code of Conduct? (Ask YCW to answer the question with an example.)
Do you have any concerns with the treatment of UC in care? Do you have concerns about any particular staff members (any staff members you think should NOT be working with UC)?
What would you do to improve or strengthen the program here?
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 youth care workers 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.