NSYC Facility Questionnaire - Double Unit

FORM APPROVED
O.M.B. No.: XXXX-XXXX
EXPIRATION DATE: XX/XXXX

DRAFT

National Survey of Youth in Custody
Facility Questionnaire

Facility name:

NSYC researchers are scheduled to visit your facility on .
This questionnaire asks about staffing and youth in this facility as of
,
the Wednesday before the NSYC visit.

1.

PERSON COMPLETING THIS QUESTIONNAIRE

Name

Email Address

Title
Facility name

Telephone
Area code

Number

Area code

Number

Extension

Facility address – Number and street/or P.O. Box/Route number

Fax Number
City

State

ZIP Code

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is xxxx-xxxx. The time required to complete this
information collection regarding the facility (Q1 – Q17) is estimated to average 30 minutes per response and information collection for each
living unit is estimated to average 10 minutes per response, including the time to review instructions, search existing data resources, gather
the data needed, and complete and review the information collection. If you have any comments concerning the accuracy of the time
estimates or suggestions for improving this form, please write to: _____________________________________. If you have any comments
or concerns regarding the status of your individual submission of this form, write directly to: _____________________________.

MUFQ 9999

DRAFT
FACILITY STATISTICS
1.

Please provide the number of staff members working at the facility as of Wednesday, . Include full- and
part-time payroll and non-payroll staff. (Examples of non-payroll staff: personnel of a parent agency or those paid
under contractual agreements/grants.)
GENDER
TOTAL

a.

2.

All staff

_____

Male

Female

_____

_____

_____

_____

For each category, please provide the number of staff members working at the facility as of Wednesday,
.


Include full and part-time payroll and non-payroll staff.



Include each staff person in only one category. If a staff member serves in more than one capacity,
categorize the person based on his or her primary role.
GENDER
TOTAL
Male

Female

LENGTH OF SERVICE
IN FACILITY
Less than
1 year or
1 year
more

a.

Front line supervision staff / correctional
officers

_____

_____

_____

_____

_____

b.

Program staff (instructors, teachers,
librarians, education assistants and other
program staff)

_____

_____

_____

_____

_____

Medical or health care staff (certified
counselors, doctors, dentists,
psychologists, psychiatrists, social
workers, nurses, and medical assistants)

_____

_____

_____

_____

_____

Administrative staff (wardens,
superintendents, assistants, office clerical,
and others in administrative positions)

_____

_____

_____

_____

_____

Other staff

_____

_____

_____

_____

_____

c.

d.

e.

3.

LENGTH OF SERVICE
IN FACILITY
Less than
1 year or
1 year
more

During the past 12 months, has there been change in the number of staff?
Yes  (Please describe the
change.)

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

No

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MUFQ 9999

DRAFT
4.

Please provide the number of volunteers working at the facility as of Wednesday, . Include full and parttime volunteers working in the facility who receive no compensation of any type.

a.

5.

Volunteers

TOTAL

GENDER
Male
Female

_____

_____

_____

Please provide the start and end times for each shift and the numbers of front line staff and other direct care
staff that worked each shift on Wednesday, . (If staff in your facility do not work standard shifts (e.g., the
facility operates “rolling shifts”), please approximate the number of staff by category working during the following time
periods: Day = 6:00am-2:00pm; Evening = 2:00pm-10:00pm; Overnight = 10:00pm-6:00am.)
Day
a.

b.

c.

6.

Evening

_______ to _______

Start and end times for each shift

Start

End

Overnight

_______ to _______
Start

End

_______ to _______
Start

End

or

or

or

Check here if no
standard shifts ,
and define the shift
as 6:00am-2:00pm.

Check here if no
standard shifts ,
and define the shift
as 2:00pm-10:00pm.

Check here if no
standard shifts ,
and define the shift
as 10:00pm-6:00am.

Number of front line supervision staff /
correctional officers from Question 2,
row a, working by shift on Wednesday,

_____

_____

_____

Number of other staff from Question 2,
rows b-e, providing direct care by shift on
Wednesday, . This would include
program staff, medical and health care
staff, administrative staff, and any other
staff with direct care responsibility during
the shift.

_____

_____

_____

This question asks about all youth in this facility on Wednesday, .
6a.

On Wednesday, , how many youth had assigned beds in this facility?
_____ youth with assigned beds

6b.

How many of these youth were adjudicated?
_____ adjudicated youth with assigned beds

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MUFQ 9999

DRAFT
PERSONNEL SCREENING
7.

Screening involves procedures that go beyond asking someone to self-disclose information. Examples of
screening include checking police records and records of other public agencies.
Please indicate whether or not any of the following are considered when screening new hires (full or part-time
payroll and non-payroll positions) and volunteers involved in direct care of youth.
Considered
for new hires
Subject

8.

Yes

a.

Criminal record

b.

Conviction for drug use

c.

Conviction for child abuse or sexual abuse

d.

Test for current drug use

e.

Psychological evaluation

No

Considered for
volunteers
(N/A=no volunteers)
Yes
No
N/A

In the past 12 months, has there been a change in this practice?
Yes  (Please describe the
change and note whether
it was in response to PREA
Standards or Guidelines.)
No

____________________________________________________________
____________________________________________________________
____________________________________________________________
____________________________________________________________

VIDEO SURVEILLANCE
9.

Currently, how many of the following areas in your facility use video surveillance?
All
a.

Classrooms/Library

b.

Entrances to sleeping areas

c.

Sleeping areas

d.

Entrances to bathrooms/showers

e.

Bathrooms/Showers

f.

Other indoor areas

g.

Outdoor recreation areas

h.

Other outdoor areas

4

Some

None

MUFQ 9999

DRAFT
10.

If your facility does not use video surveillances (i.e., all areas in Question 9 were answered “None”), check this
box
and go to Question 11.
How does your facility use the video surveillance in each of these areas?
Live
monitoring
Yes
No

11.

a.

Classrooms/Library

b.

Entrances to sleeping areas

c.

Sleeping areas

d.

Entrances to bathrooms/showers

e.

Bathrooms/Showers

f.

Other indoor areas

g.

Outdoor recreation areas

h.

Other outdoor areas

Recording for
investigation
Yes
No

Other
purpose
Yes
No

No video
surveillance

During the past 12 months, have there been any changes in video surveillance?
Yes  (Please describe the
change.)

_____________________________________________________________
_____________________________________________________________
_____________________________________________________________
_____________________________________________________________

No

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MUFQ 9999

DRAFT
FACILITY CHARACTERISTICS
12.

What type of facility is this?
Yes
a.

Detention center

b.

Training School/Long-term secure facility

c.

Reception or diagnostic center

d.

Group home/Halfway house

e.

Residential treatment center

f.

Boot camp

g.

Ranch, forestry camp, wilderness or
marine program, or farm

h.

Runaway and homeless shelter

i.

Other type of shelter

j.

Other  (Please describe the type of
facility.)

No

___________________________
___________________________
___________________________

13.

If Question 12 has only one type marked, check this box

and go to Question 14.

If Question 12 has more than one type marked, please select the primary function of this facility? (Mark only one
answer.)
Detention center
Training School/Long-term secure facility
Reception or diagnostic center
Group home/Halfway house
Residential treatment center
Boot camp
Ranch, forestry camp, wilderness or marine program, or farm
Runaway and homeless shelter
Other type of shelter
Other  (Please describe the type of facility.) ___________________________________________________
___________________________________________________

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MUFQ 9999

DRAFT
14.

We would like your estimate of the percent of youth in residence who have a history or currently have any of
these problems, conditions, or patterns of behavior.
Please think about each of the categories separately in relation to your total population. Some youth may be
represented in more than one category.
0%

15.

a.

Self-injury/suicidal

b.

Violent to others

c.

Abused by parents (physical, emotional,
and/or sexual abuse)

d.

Predatory sexual behavior

e.

Rape victimization

f.

Prostitution

g.

Gang membership/affiliation

h.

Psychiatric condition

i.

Developmental disability

1-25%

26-50%

51-75% 76-100%

During the past 12 months, how many youth have left the facility? Include youth who have been discharged,
transferred to another facility, or had some other type of exit from the facility.
______
Youth

16.

What was the average length of stay for youth who left the facility in the past 12 months? Consider the average
length of time youth spent in this facility from admission through discharge, transfer, or other type of exit from
the facility.
______ . ___
Months

OR

______
Days

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MUFQ 9999

DRAFT
17.

Within your facility, are any of the following factors considered when assigning youth to living units? (Living
units are places where youth are housed such as wings, floors, pods, dorms, barracks, or cottages. Do not include timeout or recreation rooms, classrooms, infirmary, isolation, or any location unless it is the only area in which a youth has
an assigned bed.)
Yes
a.

Offense history

b.

Risk of escape

c.

Danger to self

d.

Danger to others

e.

Age

f.

Gender

g.

Sexual orientation

h.

Special needs

i.

Other  (Please describe the factor.)

No

___________________________
___________________________
___________________________

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MUFQ 9999

LIVING UNIT CHARACTERISTICS OF
Please use this form to describe the unit named above.

E.

If youth are not assigned to this unit, please check this
box
and leave the remaining questions blank.
A.

Does the unit specialize in a particular treatment?
Yes
No  (Go to Question D)

B.

What kind of treatment does this unit specialize in?
Yes

F.

No

On Wednesday, , how many of the youth
in this unit were:
a.

Male

______

b.

Female

______

On Wednesday, , what was the age range
of youth assigned to this unit?
_____________ to _____________
minimum age
maximum age

a. Mental health treatment
b. Substance abuse
G.

c. Sex offender treatment
d. Treatment for arsonists

Makeshift beds are those used when the number of
standard beds is insufficient for the number of youth
assigned to the unit.

e. Treatment for specifically
violent offenders

____________
Beds

f. Other (Please describe.)
________________________________________

H.

________________________________________
C.

On Wednesday, , how many standard
and makeshift beds were in this unit?

If Question B has only one type marked, check
this box
and go to Question D.

On Wednesday, , how many of each type
of bed were assigned and how many were not
assigned? (The total number of beds reported in
this question should match the number reported in
Question G.)

If Question B has more than one type marked
Yes, please select the primary treatment
specialization of this unit. (Mark only one answer.)
Mental health treatment
Substance abuse treatment
Sex offender treatment
Treatment for arsonists
Treatment for specifically violent offenders
Other  (Please describe the specialization)

I.

Assigned

Not
assigned

a.

Standard beds

______

______

b.

Makeshift beds

______

______

What are the arrangements of the sleeping
rooms in this unit? (Mark only one answer.)

_________________________________________
1 youth per sleeping room
2 youth per sleeping room
3 youth per sleeping room
4 youth per sleeping room
5 to 10 youth per sleeping room
11 to 25 youth per sleeping room
More than 25 youth per sleeping room
Other  (Please describe the arrangements.)

_________________________________________
D.

Considering the youth assigned to this unit
during the past 12 months, what was the average
length of time they stayed in the unit? If a youth
was assigned to the unit multiple times, count
the length of each stay separately.
Example: One youth stayed in the unit for 6 months
and another youth stayed in the unit twice, once for
5 months and once for 3 months. These count as
three separate stays: one for 6 months, one for 5
months, and one for 3 months. The average length
of stay in this example would be 4.7 months [i.e.,
(6+5+3 months) / 3 stays].
______ . ___
Months

OR

_________________________________________
_________________________________________
J.

On Wednesday, , how many of the youth
with assigned beds in this unit were
court-adjudicated for an offense?
________
Youth

______
Days
9

MUFQ 9999

LIVING UNIT CHARACTERISTICS OF
Please use this form to describe the unit named above.

E.

If youth are not assigned to this unit, please check this
box
and leave the remaining questions blank.
A.

Does the unit specialize in a particular treatment?
Yes
No  (Go to Question D)

B.

What kind of treatment does this unit specialize in?
Yes

F.

No

On Wednesday, , how many of the youth
in this unit were:
c.

Male

______

d.

Female

______

On Wednesday, , what was the age range
of youth assigned to this unit?
_____________ to _____________
minimum age
maximum age

a. Mental health treatment
b. Substance abuse
G.

c. Sex offender treatment
d. Treatment for arsonists

Makeshift beds are those used when the number of
standard beds is insufficient for the number of youth
assigned to the unit.

e. Treatment for specifically
violent offenders

____________
Beds

f. Other (Please describe.)
________________________________________

H.

________________________________________
C.

On Wednesday, , how many standard
and makeshift beds were in this unit?

If Question B has only one type marked, check
this box
and go to Question D.

On Wednesday, , how many of each type
of bed were assigned and how many were not
assigned? (The total number of beds reported in
this question should match the number reported in
Question G.)

If Question B has more than one type marked
Yes, please select the primary treatment
specialization of this unit. (Mark only one answer.)
Mental health treatment
Substance abuse treatment
Sex offender treatment
Treatment for arsonists
Treatment for specifically violent offenders
Other  (Please describe the specialization)

I.

Assigned

Not
assigned

c.

Standard beds

______

______

d.

Makeshift beds

______

______

What are the arrangements of the sleeping
rooms in this unit? (Mark only one answer.)

_________________________________________
1 youth per sleeping room
2 youth per sleeping room
3 youth per sleeping room
4 youth per sleeping room
5 to 10 youth per sleeping room
11 to 25 youth per sleeping room
More than 25 youth per sleeping room
Other  (Please describe the arrangements.)

_________________________________________
D.

Considering the youth assigned to this unit
during the past 12 months, what was the average
length of time they stayed in the unit? If a youth
was assigned to the unit multiple times, count
the length of each stay separately.
Example: One youth stayed in the unit for 6 months
and another youth stayed in the unit twice, once for
5 months and once for 3 months. These count as
three separate stays: one for 6 months, one for 5
months, and one for 3 months. The average length
of stay in this example would be 4.7 months [i.e.,
(6+5+3 months) / 3 stays].
______ . ___
Months

OR

_________________________________________
_________________________________________
J.

On Wednesday, , how many of the youth
with assigned beds in this unit were
court-adjudicated for an offense?
________
Youth

______
Days
10

MUFQ 9999

COMMENTS SECTION
Please add any additional comments or notes in the area below.
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MUFQ 9999