OMB 0970-0564 [valid through MM/DD/2026]
(Revised: 1/5/21)
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. Please see the "Introduction Prompt for UC Questionnaire" for additional guidance.
Questions in bold should be asked during the interview if possible. Other questions are optional prompts to assist the interviewer. 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:_______________________________
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 |
Introduction |
Notes |
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Admission/Orientation |
Notes |
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Education/School |
Notes |
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Recreation/Structured Leisure Activities |
Notes |
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Religious Services |
Notes |
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Food/Snacks |
Notes |
• ¿Cómo está la comida aquí? ¿Qué tipo de cosas te gusta comer aquí? • ¿Recibe suficiente comida?
• Hábleme de los bocadillos. |
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Medical |
Notes |
If UC is receiving medications: ¿Siempre has recibido el medicamento correcto en el momento adecuado? ¿Alguna vez te has perdido de tomar el medicamento?
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Legal |
Notes |
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Interpretation Services |
Notes |
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Communication with Family |
Notes |
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Meetings with CM Staff/Reunification |
Notes |
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Clinical Services |
Notes |
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Program Rules |
Notes |
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Reporting a Complaint or Abuse |
Notes |
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Safety |
Notes |
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Conclusion |
Notes |
Re-explain that we will not say ‘who said what’ and will only share summary recommendations with program and ORR.
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Additional Notes |
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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 UC 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].
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Poole, Laura (ACF) (CTR) |
File Modified | 0000-00-00 |
File Created | 2023-11-18 |