Form M-12Es-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 (Spanish) – 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 and help the minor feel comfortable and relaxed. Allow minor to share something about themselves to 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.

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.” (Estaré tomando notas hoy de lo que hablamos. Tal vez necesite tu ayuda para asegurarme que todo este correcto).

• 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
¿Cómo te llamas? ¿Cuál es tu lugar favorito aquí? ¿Te gustaría hablar ahí? ¿Qué es tu comida o bocadillo favorito? ¿Juegas al aire libre? ¿Qué actividad disfrutas más al aire libre?

Guide for the drawing section: Build conversation around what the child is drawing. Monitor should try to provide appreciations to children’s art and respond accordingly. Remember, by 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

¿Puedes dibujarte?

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

¿Cómo te sientes hoy? ¿Puedes escoger una cara de cómo te sientes hoy o dibujar tu propia cara de cómo te sientes?

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? (¿Porque escogiste esa cara?

Document your observation and minor’s comments: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Question

¿Puedes dibujar lo que te gusta del programa? ¿Puedes dibujar lo que no te gusta del programa?

Use the response within the boxes to probe the minor. Example: Tell me about the picture you drew. (Cuéntame sobre tu dibujo).

Document your observation and minor’s comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Question

¿Hay algo más que me quieras decir? ¿Algo que me tengas que decir? Tal vez algo que no te he preguntado.

Document your observation and minor’s comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

¿Puedes dibujarte?

¿Puedes dibujar lo que te gusta del programa? 

Cuéntame sobre tu dibujo.

¿Puedes dibujar lo que no te gusta del programa? 

Cuéntame sobre tu dibujo.

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.