Form M-11P-UF Form M-11P-UF Interpreter Questionnaire

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

Revised: 3/16/2022

Staff Questionnaire – Interpreter – 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
Please explain your role and responsibilities. In which language(s) do you provide translation or interpretation services?
What training were you provided when you started this position? Are there any additional areas of training that you would find beneficial?
Describe how you collaborate with other teams (YCWs, CMs, etc.). Do you have a clear understanding of your role in relation to other teams’ roles?
Are interpretation/translation services consistently provided across different program areas? If not, please describe any additional needs. What is the process for staff or UC to request interpretation services?
Do you feel that you have the support and resources necessary to do your job? How is your relationship with your supervisor?
In which language(s) are interpreter/translation services provided? Are there any UCs at the program who do not understand those languages? If so, how are they accommodated?
Do the services (i.e. case management, religious, education, etc.) provided here seem culturally appropriate? If not, how could they be improved?
Have you had any concerns about the treatment of UC in care? If so, please explain.
Do you have any additional concerns, recommendations, or suggestions?

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 interpreters during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 0.5 hours per response for the care provider and 0.5 hours 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.