Form M-9 Form M-9 Foster Home On Site Monitoring Checklist

Monitoring and Compliance for Office of Refugee Resettlement (ORR) Care Provider Facilities

23 - Foster Home On Site Monitoring Checklist (Form M-9B)

Foster Home On Site Monitoring Checklist (Form M-9B)

OMB: 0970-0564

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Updated: 11/19/19 OMB 0970-#### [valid through MM/DD/YYYY]


Foster Home Monitoring Checklist – Walkthrough (LTFC and TFC)


General Home Information

Foster Parent Name(s):



Name of UAC:

Foster Home Licensed Capacity:

Foster Home Address:



Date of Home Visit:

# of Children in Foster Home:

Age/Gender:

Program Name:



Type of Foster Home License:

# of Adults in Foster Home:

Relationship to FP/Gender:

*** PLEASE NOTE ANY NEW/UNKNOWN NAMES, AGES, RELATIONSHIPS, and MEDICAL NEEDS of Adults or Children living or working in the home (verify all info with FP case file)***



Compliant?


Compliant?

  1. General Safety and Security

Y

N

n/a


Y

N

n/a

Cleaning chemicals inaccessible to UAC




Firearms (if applicable) inaccessible to UAC




Medical supplies/prescriptions inaccessible to UAC




Other unsafe areas inaccessible to UAC




Fire extinguishers and smoke alarms in working order (test)




Pets? (clean/dangerous)




Playground/outdoor equipment (if applicable) appears safe and age appropriate




Outdoor area secure (fences in good repair, pool, supervised access)




Carbon Monoxide detectors (if applicable, gas fuel in home)









  1. General Safety and Security
















Compliant?


Compliant?

  1. Confidentiality

Y

N

n/a


Y

N

n/a

Confidential UAC information in a secure location




Case files being maintained indefinitely by program




Only individuals with a need to know basis have access to the case files




Case files safe from physical damage




Private place for UAC to make phone calls (if applicable)




Telephones/Cell Phones available for UAC to make PREA related calls (best practice)






  1. Confidentiality












Compliant?


Compliant?

  1. General Home Structure

Y

N

n/a


Y

N

n/a

Clean and Safe (windows/door locks)




Kitchen




Child-friendly (e.g. no safety/trip hazards)




UAC dietary restrictions posted/accessible




Home is properly maintained (including furniture)




Food stored in a sanitary manner




Infants/toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)




Knives/sharp objects inaccessible to youth




Well-ventilated








Adequately heated/cooled




Bathrooms




Child-to-parent ratio met




Soap








Toilet paper




Bedrooms




Working toilets




Separate by gender (per state licensing)




Hot/cold water




Natural light/dark at night




Appropriate privacy




Private place to store personal items/clothing




Hygiene/grooming items




UAC provided appropriate clothing/footwear




Towels




Provision of appropriate linens








Adequately accommodate all UAC










  1. General Home Structure











Compliant?


Compliant?

  1. Documents that should be accessible to youth

Y

N

n/a


Y

N

n/a

Phone numbers for UAC to report sexual abuse/harassment (best practice)




Grievance procedures posted




Program rules posted




Extra copies of UAC grievance forms




Foster home rules




Evacuation procedures posted prominently on each floor





  1. Documents that should be accessible to youth















Foster Home Monitoring Checklist – Other




Observed?


Observed?

Services to Potentially Observe

Y

N

n/a


Y

N

n/a

Recreation – large muscle, outdoors




Chore assignments




Meals















Reviewed?

Logs/Schedules to Potentially Review

Y

N

n/a

UAC documents maintained by the foster parent (phone logs, prescription logs, recreation logs/calendar, fire drill logs etc.)






Other 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 Monitoring Team staff to document their findings during the walkthrough portion of biennial site visits. Public reporting burden for this collection of information is estimated to average 0.5 hours per response (if the site visit is performed by a 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 [email protected].

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