Form M-9B-UF Unlicensed Facility Foster Home Onsite Monitoring Checkl

Updated: 12/9/22 OMB 0970-0564 [valid through MM/DD/2026]

Foster Home Monitoring Checklist – Walkthrough (LTFC and TFC) – Unlicensed Facility (UF) Quarterly Health and Safety Visit¹

General Home Information
Foster Parent Name(s):	Name of UC:	Foster Home Licensed Capacity:
Foster Home Address:	Date of Home Visit:	# of Children in Foster Home:	Age/Gender:
Program Name:	Type of Foster Home License:	# of Adults in Foster Home:	Relationship to FP/Gender:

*** PLEASE NOTE ANY NEW/UNKNOWN NAMES, AGES, RELATIONSHIPS, and MEDICAL NEEDS of Adults or Children living or working in the home (verify all info with FP case file)***

	Compliant?				Compliant?
General Safety and Security	Y	N	n/a		Y	N	n/a
Cleaning chemicals inaccessible to UC				Firearms (if applicable) inaccessible to UC
Medical supplies/prescriptions inaccessible to UC				Other unsafe areas inaccessible to UC
Fire extinguishers and smoke alarms in working order (test)				Pets? (clean/dangerous)
Playground/outdoor equipment (if applicable) appears safe and age appropriate				Outdoor area secure (fences in good repair, pool, supervised access)
Carbon Monoxide detectors (if applicable, gas fuel in home)

1. General Safety and Security

	Compliant?
Confidentiality	Y	N	n/a
Confidential UC information in a secure location
Only individuals with a need to know basis have access to the case files
Private place for UC to make phone calls (if applicable)

2. Confidentiality

	Compliant?				Compliant?
General Home Structure	Y	N	n/a		Y	N	n/a
Clean and Safe (windows/door locks)				Kitchen
Child-friendly (e.g. no safety/trip hazards)				UC dietary restrictions posted/accessible
Home is properly maintained (including furniture)				Food stored in a sanitary manner
Infants/toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)				Knives/sharp objects inaccessible to youth
Well-ventilated
Adequately heated/cooled				Bathrooms
Child-to-parent ratio met				Soap
				Toilet paper
Bedrooms				Working toilets
Separate by gender (per state licensing)				Hot/cold water
Natural light/dark at night				Appropriate privacy
Private place to store personal items/clothing				Hygiene/grooming items
UC provided appropriate clothing/footwear				Towels
Provision of appropriate linens
Adequately accommodate all UC

3. General Home Structure

	Compliant?				Compliant?
Documents that should be accessible to youth	Y	N	n/a		Y	N	n/a
Phone numbers for UC to report sexual abuse/harassment (best practice)				Grievance procedures posted
Program rules posted				Extra copies of UC grievance forms
Foster home rules				Evacuation procedures posted prominently on each floor

4. Documents that should be accessible to youth

Foster Home Monitoring Checklist – Other

	Observed?				Observed?
Services to Potentially Observe	Y	N	n/a		Y	N	n/a
Recreation – large muscle, outdoors				Chore assignments
Meals

			Reviewed?
Logs/Schedules to Potentially Review			Y	N	n/a
UC documents maintained by the foster parent (phone logs, prescription logs, recreation logs/calendar, fire drill logs etc.)

Other Notes

1 Unlicensed Facility Quarterly Health and Safety Visits are performed for long-term group homes. ORR does not operate unlicensed long-term foster care or transitional foster care programs.

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 staff to document their findings during the walkthrough portion of 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].