Form M-11K-UF PSA Compliance Manager Questionnaire

1 | Page

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

(Revised: 3/16/2022)

Staff Questionnaire – PSA Compliance Manager – Unlicensed Facility (UF) Quarterly Health and Safety Visit

Interview Details
Program Name:	Past and Current Position(s) at Program:
Level of Care:	Date/Time of Interview:
Full Name:	Interviewer:

*Note: Before beginning the interview and/or providing this questionnaire to staff, provide a brief introduction, including monitor’s role and purpose of monitoring visit, confidentiality of staff interview, and clarify any questions. See Introduction Prompt for Staff for additional guidance as needed. Questions in bold should be asked during the interview if possible. Other questions are optional prompts to assist the interviewer.

	NOTES
Tell me about your role and main responsibilities as a PSA Compliance Manager. Do you also serve in other positions/roles? If so, what positions/roles? Do you feel that you have enough time to manage all of your PSA responsibilities?
What are the things that you love/enjoy about your job? What are the challenges you face in your job?
Do you feel that you receive adequate training from your program/and from ORR to perform your PSA duties? If not, please explain. What additional training from your program/and from ORR do you think a person in your position would benefit from?
Describe your system to assess ongoing staff training needs and opportunities for development? How is this working? As a PSA Compliance Manager, explain how you ensure completion of required and developmental trainings? Please describe any training needs that your staff currently has.
How do you keep up-to-date on current and new ORR policies and procedures?
Describe the procedures when there is an allegation of sexual abuse/sexual harassment. What community resources are available to UAC victims of sexual abuse and sexual harassment? Describe options for staff members to elevate issues of concern related to the treatment of UACs in care.
When are UC provided with orientation on topics related to preventing, detecting and responding to sexual abuse and harassment? Who provides this training? How often does your program provide UC refresher orientations? How do you ensure orientation and refresher orientations have been completed?
How do you monitor the quality and timely reporting of SA/SIRs? What quality assurance measures are in place? Do you have oversight responsibilities of UC case files or foster parent files, if applicable? If so, how often are files reviewed? What tools do you use? How are results from audits/reviews used to improve services at the program?
How do you meet the state’s licensing requirements regarding significant incident reporting?
Describe any concerns you have with how the program and staff are adhering to PSA compliance. What are some of the challenges the program has faced related to PSA compliance? Many of the PSA trainings and refreshers from ORR describe boundary crossings versus boundary violations. Tell me how your program handles boundary issues.
What actions are taken when areas of non-compliance related to PSA issues are identified? (LTFC and TFC only) How about specifically in foster homes?
What does trauma-informed care mean to you? How do you deliver trauma-informed care as part of the PSA team?
How do you ensure that all UC disclosures during the Assessment for Risk are reported in accordance with ORR policies and procedures? Examples: Information about sexual orientation and gender identity is kept confidential and is only shared when disclosure is necessary; the child’s self-identification of his or her gender and safety needs is taken into consideration when determining housing and other services.
Provide some examples of protection measures to ensure the safety and security of UC victims of sexual abuse and sexual harassment. Examples: Change housing assignments in the facility; transfers for UAC victim and/or perpetrator; provide emotional support services for UAC who fear retaliation for reporting sexual abuse or sexual harassment or cooperating with investigations; access to forensic examination.
How do you collaborate with other teams to ensure that UCs’ physical, mental health, developmental, social and educational needs are being met? What recommendations do you have to strengthen the collaboration and communication with other departments?
Describe the program’s protocol for utilizing and reviewing the video monitoring system. How is the video monitoring system used to enhance your ability to protect UC from sexual abuse and sexual harassment while maintaining their privacy? Who reviews the footage? How often? How long is video footage stored?
Do you have any concerns about the treatment of UCs in care? Do you have concerns about any particular staff members (any staff members you think should NOT be working with UC)?
What general recommendations do you have to strengthen the program? What improvements would you put in place? Have you shared these ideas with your supervisor or any other program staff?
What recommendations do you have for ORR that I can take back to share with our headquarter teams?

Additional Notes

Enter Additional 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 contractor monitors to interview and document responses from prevention of sexual abuse compliance managers during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 1 hour per response for the care provider and 1 hour per response for the 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].