Form M-12B-UF Unlicensed Facility Unaccompanied Child Questionnaire -

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

(Revised: 3/16/2022)

UC Questionnaire / Ages 13 and Older – Unlicensed Facility (UF) Quarterly Health and Safety Visit

Instructions: The interviewer should explain to the minor that the interview is not mandatory and confirm that he/she is voluntarily participating in the interview without their attorney(s) present. The interviewer should also explain to the minor the monitor’s role, the purpose of the interview, and the use/role of an interpreter (if applicable). Explain the purpose of your visit in child friendly terms and answer any questions the UC has about ORR or your visit. Also, reassure minor to not be nervous if he/she is nervous about the interview. Please see the "Introduction Prompt for UC Questionnaire" for additional guidance.

Questions in bold should be asked during the interview if possible. Other questions are optional prompts to assist the interviewer. These questions are NOT intended to be asked verbatim. Ask questions that help establish rapport. The UC monitor should ask individualized interview questions based upon the UC case file review and the circumstances of the inspection.

Name of witness present confirming minor volunteered to be interviewed without their attorney(s) present:_______________________________

Interview Details

UC Name:	A#:
Date of Admission:	Gender/Age:
Date/Time of Interview:	Country of Origin:
Name of Evaluator:	Name of Interpreter:
Primary Language of UC:	Language of Interview:
Appropriately dressed? Yes No	Appropriately groomed? Yes No

Introduction	Notes
What is your name? Tell me about what you do on a typical day here. (Explore schedule, meals/nutrition, recreation, activities) What are the things you like about the program? What are the things you don’t like about the program?
Admission/Orientation	Notes
Tell me about what happened when you first arrived at the program. Was orientation provided in your primary/preferred language? If needed, were orientation materials translated and/or interpreted for you? What do you remember about: Phones? Sexual Abuse/Sexual Harassment? Mail/Visits? Grievance Procedures? Clothes? Did staff help you feel comfortable and explain things?
Education/School	Notes
Tell me about your experience in school here. What is a normal school day like? What classes do you take? Are classes offered in your primary/preferred language? Do you enjoy going to school? Do you feel like your teachers really care about your education? If there is any doubt they are receiving all of the required subjects (Science, Social Studies, Math, Reading, Writing, Physical Education, and English as a Second Language): Are you taking a class on ___________? What are you learning in that class? If there is any doubt they are receiving the required hours of instruction: Do you have class every day, Monday to Friday? How long do you spend in school each day?
Recreation/Structured Leisure Activities	Notes
Tell me about the activities you do outside of school. What kinds of activities do you do? Where do you go? Do you go on outings to parks, museums, or other places in the community? How often? How often do you go outside for exercise? If the weather is bad, do you do exercise indoors (outside of PE class)? Do you have quiet/leisure time in which you can choose to read a book, play board games with other kids, do art, play cards, etc.?
Religious Services	Notes
Are you given a choice about participating in religious services? (Are you pressured to attend religious services?) Are religious books offered in your primary/preferred? Are you given all of the supplies needed to practice your religion (i.e., sacred texts (Bible, Quran, etc.), clothing, religious articles (prayer beads/rosaries, prayer mats, etc.), hygiene products (razors), etc.)? Are you allowed to display your religious art? Wear religious pieces? Are you able to participate in holidays of your choosing? Are you allowed the time needed to practice your religion? What kinds of religious services are offered here?
Food/Snacks	Notes
How is the food here? Does the food that is provided meet your religious dietary needs? What kinds of things do you like to eat here? Do you receive enough food? Tell me about the snacks.
Medical	Notes
If you’re not feeling well, who do you talk to? How do they respond? Quickly enough? Do you have any health concerns? Have they been addressed? Do you currently take any medication? If so, who provides the medication for you? Do you know why you are taking the medication? Do you remember when you first visited the doctor? Why did you go? Who took you? What is the process to request medical care? Depending on time in care: Have you visited the dentist? If UC is receiving medications: Have you always received the right medication at the right time? Have you ever missed a dose? Do you feel like the medical staff care about you and treat you with respect?
Legal	Notes
When you arrived at the program, did you attend a “Know Your Rights” presentation? Did you receive a Legal Resource Guide, which has a list of free attorneys for the state you are in? Do you know that you have a right to talk to an attorney? Have you ever been denied access to legal assistance while at the program? If so, please explain. What can you do if you believe you have been denied your rights or access to the required legal services?
Interpretation Services	Notes
Are you provided with services in your primary/preferred language? Are you able to make requests for services and/or communicate with staff in your primary/preferred language?
Communication with Family	Notes
Are you able to contact your family/sponsor? How often are you able to contact your family/sponsor? How long are you able to speak with them? How do you keep in contact with them? Where do phone calls occur? Do you feel that the staff is listening to your calls?
Meetings with CM Staff/Reunification	Notes
Tell me about your meetings with your case manager. (Explore whether UC understands the role of the case manager, how often they meet, what they do during meetings) Tell me about the progress of your case. I assume there was a plan in place when you decided to come to the U.S. Did the plan change? Who helps you with your actual/new plan? Do you have a say/input in your plan? (Explore the role of the CM helping UC with their plans)
Clinical Services	Notes
Tell me about the sessions with your clinician. (Explore whether UC understands the role of the clinician, how often they meet, if comfortable during 1:1 meeting, what they do during sessions) Do those sessions help you? If so, how? If not, how could the sessions be improved? Which sessions do you prefer: individual or group sessions? Why? Do you think the individual sessions are private? Would you change your clinician if you could?
Program Rules	Notes
What happens when you break a rule or get in trouble? What about when other children here break a rule? Do you think the consequences for breaking rules are fair? Have you ever been hurt physically by a staff member? Or treated disrespectfully? Are there any staff here that don’t treat you with dignity and respect? Do staff here ever act angry or mad?
Reporting a Complaint or Abuse	Notes
If you have a complaint about the program or about staff, who do you talk to? Are there any particular staff you feel comfortable talking to? Is there a form where you can a write down a complaint? Where are these forms located? Have you ever made a complaint/grievance? If so, how did the program and staff respond? If you need to report that something happened, such as abuse, how would you do it? Do you know how to use the phone to report abuse? If yes, where are the phones and how are they used? Do you have to ask permission to use the phone? If the interview is taking place near the pre-programmed phone, see if the UC can demonstrate how to use it.
Safety	Notes
Have you always felt safe here? If yes, what makes you feel safe? If no, describe why you do not feel safe at the program. If the child discloses feeling unsafe, the evaluator must elevate the issue for appropriate action, including connection with clinician when necessary. Tell me what you like most about the staff here. Tell me what you don’t like about the staff. Are there any staff members who you avoid or who should not be working with UCs? Are there any staff members who make you feel uncomfortable? Which staff member has been most helpful and responsive to your needs? Have you ever been treated badly or with disrespect? (Yelled at? Cursed at? Made fun of by staff? Bullied by other UC in front of staff?) Have you ever witnessed another child being treated badly or bullied while here?
Conclusion	Notes
Re-explain that we will not say ‘who said what’ and will only share summary recommendations with program and ORR. If there was one thing you could change about this program what would it be? Is there anything you feel the caregivers could do better? Is there anything else you want to tell me? Or should tell me? Maybe something I haven’t asked you?
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 UC 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 UC 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.