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

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

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(Revised: 3/16/2022)

UC Tender Age Questionnaire / 5 years old and under – 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 they are participating voluntarily 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 the minor to not be nervous if about the interview and help the minor feel comfortable and relaxed. Allow minor to share something about themselves if that would help. Please see the "Introduction Prompt for UC Questionnaire" for additional guidance.

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, taking the individual needs of child into account.

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

• Remind the minor: “I will be taking notes about what we will talk about today, so that I can remember everything you tell me. Sometimes I might need your help to make sure I get everything right.”

• If necessary, during the introduction, consider using the support from program staff and/or the foster parent(s) to build trust

UC Monitor’s observation notes for infants and/or non-verbal children if applicable:	Notes
Describe the infant or none-verbal child’s activity. (i.e. napping, eating, playing, etc.) Describe the environment. (i.e. outlet covers, toys, high chair, diapers, clothing) How is the staff/foster parent/minor’s parent interacting with child?

Introduction	Notes
What is your name? (UC in Foster Care) Where is your favorite place to be inside your foster home? Would you like to talk there? What is your favorite food/snack? Do you play outside? What is your favorite outside game?

Guide for the drawing section: Build conversation around what the child is drawing. Monitor should try to provide appreciation of the child’s art and respond accordingly. Remember, asking the child about their picture shows that you are interested in what they are doing, feeling, and thinking.

Examples

• Look at it through the child’s eyes.

• Ask questions regarding the child’s color choices and methods.

• Appreciate their efforts. Give specific feedback. Try to avoid comments like “What a beautiful picture!” or “Good job!”

Question

Will you draw me a picture of yourself?

Use the drawing within the box as an indicator of the child's developmental level and to get a sense of the child's perception of his/herself.

Document your observation: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Question

Will you tell me how you are feeling today? Will you choose a face that shows how you are feeling today, or draw your own picture of how you are feeling?

If the minor used the drawing sheet, use the responses within the drawing sheet to initiate further discussion. Example: Tell me why you selected this face?

Document your observation and minor’s comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Question

Will you draw me a picture of what you like about the program and/or foster home? Will you draw me a picture about what you do not like about the program and/or foster home?

Use the response within the boxes to probe the minor. Example: Tell me about the picture you drew.

Document your observation and minor’s comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Question

Is there anything else you want to tell me? Or should tell me? Maybe something I have not asked you. (Depending on child’s age and/or understanding)

Document your observation and minor’s comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Will you draw a picture of yourself?

Can you draw me what do you like about the program and/ or foster home J

Tell me about your drawing

Can you draw me what you do not like about the program and/or foster home L

Tell me about your drawing

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.