Form M-12D Form M-12D Secure Client Questionnaire

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

47 - Secure Client Questionnaire (Form M-12D)

Secure Client Questionnaire (Form M-12D) - Respondents

OMB: 0970-0564

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OMB 0970-#### [valid through MM/DD/YYYY]


Secure Client Questionnaire

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


The Monitor 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 Monitor should also explain to the minor the monitor’s role, the purpose of the interview, and the use/role of an interpreter (if applicable). Remind the minor that we are different from ICE and the purpose of our visit in child friendly terms. Also, reassure minor to not be nervous if he/she is nervous about the interview.

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


  • How do you feel today?

  • What did you do today/last night?


  • How long have you been at the facility?

    • When you first arrived, did someone explain to you why you were placed in this program? Yes NO What was the reason given?



    • What other information were you provided during orientation? (program rules? UC rules and responsibilities? grievances?)


    • Did you get to see the nurse/doctor? Yes NO


    • What happened to your belongings?


    • What clothing and hygiene items were you provided? Do you currently have enough?


  • When you need personal care items like soap and clothes, who can you ask?

    • Do you feel comfortable asking for more items?


  • Did anyone show you how to exit the building in case of an emergency (fire, hurricane, etc.)? Yes NO

  • How do you get along with staff?


  • How many staff members supervise at a time?

    • Education?

    • Recreation?

    • Moving from place to place?

    • Have you ever left the program for any reason (dentist, doctor, immigration related reason?) If so, how many officers/staff members were there with you?






  • Do you ever get locked down? Yes NO

    • How many times a day does this occur?

    • What are the reasons for the lock downs?



  • Are you allowed to make phone calls? Yes NO

    • Family?

    • Attorney?

    • Consulate?

    • Assigned CM?

    • How many calls are you provided per week? For how long?

    • Have you ever been denied a phone call?

    • Can you send mail? Yes NO



  • Are you allowed to have visitors? Yes NO

    • Who can visit?

    • How often?/When?


  • Do you get daily exercise? Yes NO

    • How long?

    • How often?

    • What kinds of exercise do you get to do?


  • Do you go to school? Yes NO If yes:

    • When/ how often?

    • How many days after you arrived did you start school?

    • What subjects do you study in school?


Spanish

English

Science

Math

Gym

Social Studies/ History


    • Do you have the supplies and books to learn in school and to do homework? Yes NO

    • Do you like the school? Yes NO Why?


  • Are you offered religious services of your choice? Yes NO

    • How often do you go?


  • Have there been conflicts between UC? Yes NO

    • How has staff resolved them?


  • Have you had issues with staff? Yes NO

    • What happened?

    • Have you ever been restrained? If so, why? How were you restrained?

    • What is the behavior system? How do you move between levels?


  • Are you able to speak to a clinician if you feel bad? Yes NO

    • Is he/she accessible?

    • How often do you meet him/her? Do you feel that he/she is helpful?


  • How often do you meet with your case manager?

    • Do you feel that she/he is helpful and keeps you informed about the status of your discharge?


  • Do you attend group counseling? Yes NO

    • If yes, how often?

    • What do you talk about in your meetings? What have you learned?

  • Do you like the food here? Yes NO

    • When/ how often do you eat?

    • Do you receive enough food/snacks? Yes NO

  • Do UCs get along with staff? Yes NO


  • Are you on any medications? Yes NO

    • Do you know why you are taking those medications?

    • What happens if you have a problem with your medications? Who can you tell?


  • Have there been any fights between UC when staff were not present? Yes NO



  • Are there any issues with peers bullying or teasing? Yes NO

    • If yes, do staff members know and what have they done to address the issue?



  • What happens if a rule is broken?

    • Where you ever told that you did not follow the rules?



  • Do you know the status of your case? Yes NO



  • Has the program explained the grievance policy? Yes NO

    • What is the process for filing a grievance?

    • Have you ever filed a grievance?



  • Do you feel safe? Yes NO


  • Did anyone tell you we were coming to visit? Yes NO

    • If yes, what did they say?



  • Is there anything else you want to tell me? Any ideas to improve the program?


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 interview and document responses from UAC during biennial site visits. Public reporting burden for this collection of information is estimated to average 0.5 hour per response (plus an additional 0.5 hour 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].

Shape1

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleClient Questionnaire
AuthorDHHS
File Modified0000-00-00
File Created2021-02-15

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