Form M-13E-UF Form M-13E-UF Unlicensed Facility Case Coordinator Questionnaire

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

(Revised: 3/16/2022)

Stakeholder Questionnaire – GDIT Case Coordinator – Unlicensed Facility (UF) Quarterly Health and Safety Visit

Interview Details

Program name:
Level of Care:
Stakeholder’s Name:
Date/Time of Interview:
Type of Interview (phone and/or face-to-face):
Interview Completed by:

Note: Before beginning the interview and/or providing this questionnaire to stakeholders, provide a brief introduction, including monitor role and purpose of monitoring visit, overview/purpose of interview, and clarify any questions. See Introduction Prompt for Stakeholders 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

Describe your history working with ORR care providers and/or UCs? How long have you been working with this program?
Tell me about how your case staffing works?
Do you find that case management and clinical staff are aware of and prepared to discuss case happenings? Do you find that case management and clinical staff have a collaborative means of addressing the issues during case staffing?
Describe how cases of concerns are elevated to the FFS’s attention.  Are there areas of improvement for this process?  What works well?
Are you provided with all the information you need to be able to make a timely release recommendation? What may cause delays in a release?
In your opinion, how is the program doing in ensuring safe and timely releases?
Do you have any issues/concerns to share with us?
Do you have any suggestions for improving the program or the case staffing process?

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 legal service providers during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 1.hour per response for the case coordinator 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].