Form M-9A-UF Unlicensed Facility On-Site Monitoring Checklist

OMB 0970-0564 [valid through MM/DD/2026]

Unlicensed Facility Quarterly Health and Safety Monitoring Checklist – Facility Walkthrough

	Compliant?				Compliant?
General Safety and Security	Y	N	n/a		Y	N	n/a
Controlled entry/exit of premises				Knives/sharp objects inaccessible to UC
Prohibited from allowing entry of any individual (except UC in the process of admission) who meet any COVID-19 criteria				Cleaning chemicals maintained in a locked area
Alarms system for all areas of the residential structure				Medical supplies/prescriptions inaccessible to UC
Video monitoring in common and living areas and classrooms				Other unsafe areas inaccessible to UC
Video monitoring for exterior of building & surrounding premises				Vehicle(s) inspection stickers up-to-date
Ability to download video footage permanently				Vehicle(s) appear to be in good repair (including fire extinguisher and first aid kit)
System for tracking and regulating UC movement				Vehicle (s) contain working seat belts
Meeting UC to floor staff ratios/appropriate supervision				Evacuation procedures posted prominently on each floor and at eye level for children and youth
“Mirrored windows”/window in offices where staff meet with child 1:1				Fire extinguishers and smoke detectors in good working order and inspected (as required)
Infants/Toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)				Play equipment safe and in good repair

	Compliant?				Compliant?
Confidentiality	Y	N	n/a		Y	N	n/a
Case files in secure location (open and closed)				Case files safe from physical damage
Only individuals with a need to know basis have access to the case files				Pre-programmed telephones (Required: UC SA Hotline, CPS, Local Community Service Provider; Highly recommended: Top 3 consulates and LSP)
Private place for UC to make phone calls (including pre-programmed phones)

	Compliant?				Compliant?
General Residential Structure - Indoors	Y	N	n/a		Y	N	n/a
Clean				Kitchen
Child-friendly (e.g. no safety/trip hazards)				UC dietary restrictions posted/accessible
Furniture and building are properly maintained				Food stored in a sanitary manner
Well-ventilated				Bathrooms
Adequately heated/cooled				Soap
Identified UC Medical Quarantine/Isolation Space				Toilet paper
Bedrooms				Working toilets
Natural light/Dark at night				Hot/cold water
Provision of appropriate linens				Separated by gender
Adequately accommodate all UC (per State Licensing)				Appropriate privacy
Separated by gender (per licensing)				Hygiene/grooming items
Adequately accommodate all youth (e.g. individual bed with mattress for each youth)				Towels
Provision of appropriate bed linens

	Compliant?				Compliant?
Documents that should be posted/accessible to youth (Spanish, English, and any other language as needed)	Y	N	n/a		Y	N	n/a
Posters with phone numbers for UC to report sexual abuse/harassment				Care Provider AND ORR Pamphlets on sexual abuse/harassment
Notice to Pregnant Females (Garza vs. Azar) next to posters				Extra copies of UC grievance forms
Grievance Procedures (in common areas)				Program Rules
Saravia Notice (English and Spanish posted next to Garza and Sexual Abuse/Harassment notices) – posting currently applicable to Secure, Staff Secure and RTC – effective 10/22/2020

	Compliant?				Compliant?
Other	Y	N	n/a		Y	N	n/a
UC/Staff provided/wearing face masks and/or offered face masks, as applicable				Emergency Evacuations Notification List (must be posted in office area and includes: ORR contacts, DHS contact, and local law enforcement)
Car Seats (if transporting young children)				No Touch Thermometers available
Sufficient supply of Face Mask / Hand Sanitizers / Gloves

Walkthrough NOTES

1. General Safety and Security

2. Confidentiality

3. General Residential Structure

4. Documents that should be posted

5. Other

On-Site Monitoring Checklist - Other

	Observed?				Observed?
Services to Potentially Observe	Y	N	n/a		Y	N	n/a
Education				Group counseling/community meeting
Recreation – large muscle, outdoors				Meals

	Reviewed?				Reviewed?
Logs/Schedules to Potentially Review	Y	N	n/a		Y	N	n/a
Fire Drills Logs				Grievance binder
Daily (Shift) logs				Group Counseling Curriculum
System for inspecting vehicles				Visitor Logs
Prescription/Non-prescription medication logs				Care Provider Policies for UC to Request Emergency and Non-Emergency Health Care Services
Spot Inspections and Quarterly Safety Assessments				UC Temperature Tracker
Facility inspection checklist (safety check)

Other NOTES

Services to Observe

Logs to Review

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 document their findings during the walkthrough portion of unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 4 hours per response, 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].