Form M-12A-UF Unlicensed Facility Unaccompanied Child Questionnaire -

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

(Revised: 3/16/2022)

UC Questionnaire / 6-12 Years Old – Unlicensed Facility (UF) Quarterly Health and Safety Visit

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 and help the minor feel comfortable and relaxed. Allow minor to share something about themselves to help. 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:____________________________________________

Interview Details

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

• Remind the minor: “I will be taking notes about what we will talk about today, so that I can remember everything you tell me. Sometimes I might need your help to make sure I get everything right.”

Introduction	Notes
What is your name? Before we start, do you have any questions for me? (UC in Foster Care) Where is your favorite place to be inside your foster home? Would you like to talk there? What is your favorite food/snack? Do you play outside? What is your favorite outside game?
Admission/Orientation	Notes
What do you remember when you first came to the program and/or foster home? (depending on child’s age and/or understanding) What items were you given when you arrived here? (depending on child’s age and/or understanding) Clothes? Shoes? Good Touch, Bad Touch/Sexual Abuse/Sexual Harassment? Mail/Visits? Grievance Procedures? Was orientation provided in your primary/preferred language? If needed, were orientation materials translated and/or interpreted for you? Do you remember having a conversation about a telephone and the purpose of it? Can you show me how the telephone(s) work? (Depending on location of telephone, child’s age and/or understanding)
Education/School	Notes
Tell me about school. Are classes offered in your primary/preferred language? What are some of the things you like about school? What are some of the things you do not like about school? Can you name some of the class subjects? Tell me one thing that you learned at school this week.
Medical	Notes
If you felt sick, who would you tell? Has there been a time when you’ve felt sick since being here? If so, tell me about what happened.
Communication with Family	Notes
Are you able to talk with your family over the phone? How often and how long do you speak with them?
Interpretation Services	Notes
Are you provided with services in your primary/preferred language? Are you able to make requests for services and/or communicate with staff in your primary/preferred language?
Program Rules	Notes
Can you tell me some of the rules here at the program or in your foster home? Can you tell me what would happen if you or another child here did not follow the rules? Can you tell me about an example of when that happened?
Reporting a Complaint or Abuse	Notes
Have you ever been hurt by a staff member or someone in your foster home? Do staff members or anyone in your foster home ever act angry or mean to you? (If so, can you tell me an example of when that happened?)
Safety	Notes
Do you always feel safe here (at the program or foster home)? If yes, what makes you feel safe? If no, please tell me some examples of when you did not feel safe. If the child discloses feeling unsafe, the evaluator must elevate the issue for appropriate action, including connection with clinician when necessary. Is there anyone at the program or in your foster home who makes you feel uncomfortable? If so, please explain. If safety of UC is a concern, please ask more questions to the UC. Some examples below may be helpful: Tell me what you like most about the staff here. Tell me what you don’t like about the staff. Are there any staff members who you avoid or who should not be working with children? Are there any staff members who make you feel uncomfortable? Which staff member has been most helpful and responsive to your needs? Have you ever been treated badly or with disrespect? (Yelled at? Cursed at? Made fun of by staff? Bullied by other children in front of staff?) Have you ever witnessed another child being treated badly or bullied while here?
Food/Snacks	Notes
Tell me about the food here. Do you think you get enough food here? Does the food that is provided meet your religious dietary needs? What kinds of things do you like to eat here?
Recreation/Structured Leisure Activities	Notes
Do you feel you get enough playtime here? Please explain.
Religious Services	Notes
Are you given a choice about participating in religious services? (Are you pressured to attend religious services?) Are religious books offered in your best/primary/preferred language you understand/prefer? Are you given all of the supplies needed to practice your religion (i.e., sacred texts (Bible, Quran, etc.), clothing, religious articles (prayer beads/rosaries, prayer mats, etc.), hygiene products (razors), etc.)?  Are you allowed the time needed to practice your religion? Are you happy with the options for religious services that are provided to you?
Conclusion	Notes
Re-explain that we will not say ‘who said what’ and will only share summary recommendations with program and ORR, unless there is something serious that needs to be elevated to leadership. If there was one thing you could change about this program what would it be? Is there anything else you want to tell me? Or should tell me? Maybe something I haven’t asked you? (depending on child’s age and/or understanding) Do you have any suggestions to improve the program? (depending on child’s age and/or understanding)

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 monitor to interview and document responses from UC during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 0.5 hours per response for the UC and 0.5 hours 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].