CJRP- JRFC Pilot Test

JRFC Questionnaire

Appendix E: JRFC Questionnaire

All changes from the 2020 JRFC instrument are denoted with red font. Variable names and question numbering may be different.

Table of Contents

INTRO PAGES 1

SECTION 0: FACILITY AND CONTACT INFORMATION 2

SECTION 1: GENERAL FACILITY INFORMATION 4

SECTION 2: BEHAVIORAL/MENTAL HEALTH SERVICES 24

SECTION 2b: MEDICAL SERVICES 33

SECTION 3: EDUCATIONAL SERVICES 36

SECTION 4: SUBSTANCE ABUSE SERVICES 40

SECTION 5: THE LAST MONTH 47

SECTION 6: THE LAST YEAR 54

SECTION 7: GENERAL INFORMATION 57

END PAGES 58

INTRO PAGES

LOGIN
ASK	All Respondents
Welcome to the 2021 Juvenile Residential Facility Census (JRFC) Pilot Study. Your participation in this pilot study will help improve the ongoing JRFC data collection. The JRFC provides comprehensive and reliable statistical data on the residential placement of juvenile offenders; facilitates the needs of juvenile justice agencies and social service organizations that address the many problems faced by today’s youth; and gathers the most complete and accurate information regarding issues of juvenile detention, correction, and placement. Thank you for your participation in this endeavor. Please enter the password provided in the mailing packet sent to your facility. <i>Please note that the password is case sensitive. </i>

INTRO
ASK	All Respondents
<b>Important Instructions</b> Complete this questionnaire only for <b>[FACILITY_NAME]</b>. We are not requesting forms for any additional facilities in this current round of data collection. Sessions will expire (requiring you to log back in) after 30 minutes of inactivity. A juvenile residential facility is a place where young persons who have committed offenses may be housed overnight. A facility has living/sleeping units, such as wings, floors, dorms, barracks, or cottages on one campus or in one building. Any buildings with living/sleeping units that are not on the same campus should be considered separate facilities and should not be included in this questionnaire.

SECTION 0: FACILITY AND CONTACT INFORMATION

S0_NAME_CONFIRM
ASK	All Respondents
<b>Facility and Contact Information</b> We have the following name listed for this facility. <b>[FACILITY_NAME]</b> Is this the correct name for this facility? Yes No

S0_NAME_UPDATE
ASK	If S0_NAME_CONFIRM = 2
What is the correct name of this facility?

S0_MAILADDR_CONFIRM
ASK	All Respondents
We have the following mailing address listed for this facility. <b>[FACILITY_MAILADDR]</b> Is the address below Is this the correct mailing address for this facility? Yes No

S0_MAILADDR_UPDATE
ASK	If S0_MAILADDR_CONFIRM = 2
What is the correct mailing address for your facility?

S0_PHYSADDR_CONFIRM
ASK	All Respondents
We have the following physical address listed for this facility. <b>[FACILITY_PHYSADDR]</b> Is this the correct physical address for this facility? Yes No

S0_PHYSADDR_UPDATE
ASK	If S0_PHYSADDR_CONFIRM = 2
What is the correct physical address for your facility?

SECTION 1: GENERAL INFORMATION

S1_OWN
ASK	All respondents
<b>NOTE:</b> The next few questions ask about who OWNS this facility. Later you will be asked who OPERATES this facility. 15a. Is this facility OWNED by one or more of the following? <i> Select all that apply</i> A private non-profit agency A for profit agency A government agency

S1_OWN_NAME
ASK	If S1_OWN = 1, 2 or missing
15b. What is the name of the private non-profit or for-profit agency that OWNS this facility?

S1_OWN_GOVTLEVEL
ASK	If S1_OWN = 3 or missing
16. What is the level of the government agency that OWNS this facility? <i> Select all that apply.</i> A Native American Tribal Government Federal State County Municipal (includes Washington, DC) Other – Please specify:

S1_OPERATE
ASK	All respondents
<b>NOTE:</b> The next few questions ask about who OPERATES this facility. 17a. Is this facility OPERATED by one or more of the following? <i> Select all that apply</i> A private non-profit agency A for profit agency A government agency

S1_OPERATE_NAME
ASK	If S1_OPERATE = 1, 2 or missing
17b. What is the name of the private non-profit or for-profit agency that OPERATES this facility?

S1_OPERATE_GOVTLEVEL
ASK	If S1_OPERATE = 3 or missing
18. What is the level of the government agency that OPERATES this facility (either directly or under a contract with)? <i> Select all that apply.</i> A Native American Tribal Government Federal State County Municipal (includes Washington, DC) Other – Please specify:

S1_CLASSIFY_A
ASK	If FORM = A
13. What type of residential facility is the one listed on the front cover? <i> Select all that apply </i> <b>Detention center:</b> A short-term facility that provides temporary care in a physically restricting environment for juveniles in custody pending court disposition and, often, for juveniles who are adjudicated delinquent and awaiting disposition or placement elsewhere, or are awaiting transfer to another jurisdiction. In some jurisdictions, detention centers may also hold juveniles committed for short periods of time as part of their disposition (e.g., weekend detention). <b>Long-term secure facility: </b> A specialized type of facility that provides strict confinement and long-term treatment generally for post-adjudication committed juvenile offenders. Includes training schools, juvenile correctional facilities, youth development centers. <b>Reception or diagnostic center: </b> A short-term facility that screens juvenile offenders committed by the courts and assigns them to appropriate correctional facilities. <b>Group home/Halfway house: </b> A long-term facility that is generally non-secure and typically intended for post-adjudication commitments in which young persons are allowed extensive contact with the community, such as attending school or holding a job. <b>Residential treatment center: </b> A facility that focuses on providing some type of individually planned treatment program for youth (substance abuse, sex offender, behavioral/mental health, etc.) in conjunction with residential care. Such facilities generally require specific licensing by the state that may require that treatment provided is Medicaid-reimbursable. <b>Ranch, forestry camp, wilderness or marine program or farm: </b> These are long-term generally non-secure residential facilities often located in a relatively remote area. The juveniles participate in a structured program that emphasizes outdoor work, including conservation and related activities. <b>Runaway and homeless shelter: </b> A short-term facility that provides temporary care in a physically unrestricted environment. It can also provide longer-term care under a juvenile court disposition order. <b>Other type of shelter: </b> This includes emergency non-secure shelters where juveniles are housed short-term until another placement can be found. <b>Other: </b> This includes independent living programs and anything that cannot be classified above. – Please specify:

S1_CLASSIFY_B
ASK	If FORM = B
13. What type of residential facility is the one listed on the front cover? <i> Select all that apply </i> A short-term facility that provides temporary care in a physically restricting environment for juveniles in custody pending court disposition and, often, for juveniles who are adjudicated delinquent and awaiting disposition or placement elsewhere, or are awaiting transfer to another jurisdiction. In some jurisdictions, detention centers may also hold juveniles committed for short periods of time as part of their disposition (e.g., weekend detention). A specialized type of facility that provides strict confinement and long-term treatment generally for post-adjudication committed juvenile offenders. Includes training schools, juvenile correctional facilities, youth development centers. A short-term facility that screens juvenile offenders committed by the courts and assigns them to appropriate correctional facilities. A long-term facility that is generally non-secure and typically intended for post-adjudication commitments in which young persons are allowed extensive contact with the community, such as attending school or holding a job. A facility that focuses on providing some type of individually planned treatment program for youth (substance abuse, sex offender, behavioral/mental health, etc.) in conjunction with residential care. Such facilities generally require specific licensing by the state that may require that treatment provided is Medicaid-reimbursable. These are long-term generally non-secure residential facilities often located in a relatively remote area. The juveniles participate in a structured program that emphasizes outdoor work, including conservation and related activities. A short-term facility that provides temporary care in a physically unrestricted environment. It can also provide longer-term care under a juvenile court disposition order. Other type of shelter emergency non-secure shelters where juveniles are housed short-term until another placement can be found. Other including independent living programs and anything that cannot be classified above. – Please specify:

S1_CLASSIFY_SCREENPROG
ASK	All Respondents
Does this facility screen young persons to assign them to the appropriate program within this facility? Yes No

S1_CLASSIFY_SCREENLIV
ASK	All Respondents
Does this facility screen young persons to assign them to the appropriate living arrangement within this facility? Yes No

S1_CLASSIFY_SCREENOTH
ASK	All Respondents
Does this facility screen young persons to assign them to another facility? Yes No

S1_CLASSIFY_SCREENCOMM
ASK	All Respondents
Does this facility screen young persons to assign them to a community-based program? Yes No

S1_CLASSIFY_POP
ASK	All Respondents
Which of the following types of young persons does your facility house? <i>Select all that apply.</i> Young persons awaiting adjudication Young persons awaiting disposition Young persons post disposition awaiting placement Young persons post disposition in placement Young persons awaiting transfer to another facility within this jurisdiction Young persons awaiting transfer to another jurisdiction None of the above

S1_CLASSIFY_CONTACT
ASK	All Respondents
Are any young persons in this facility allowed contact with the community, such as attending school or vocational training, or working outside this facility? Yes No

S1_CLASSIFY_TREATPROG
ASK	All Respondents
Does this facility provide an individually planned treatment program for youth in conjunction with residential care? Yes No

S1_CLASSIFY_OUTDOOR
ASK	All Respondents
Does this facility provide a structured program for youth emphasizing outdoor experiences, such as through outdoor work or conservation training? Yes No

S1_CLASSIFY_JOBTRAIN
ASK	All Respondents
Does this facility provide a vocational training program, workforce development services, or job training? Yes No

S1_INSTRUCT
ASK	All respondents
<b>IMPORTANT INSTRUCTIONS</b> The following items ask you to use your records to provide counts of persons who had assigned beds in this facility at the end of the day on <b>[REF_DATE]</b>. This date has been chosen carefully to give a standardized count of persons in facilities like yours across the country. You will be asked to classify your facility population into two age groups: those persons under age 21; and those persons age 21 and older. You will then be asked to classify each person UNDER THE AGE OF 21 into just one of the two following categories: those here because they have been charged with or court-adjudicated for an offense. An offense is any behavior that is illegal in your state for underage persons alone or for both underage persons and adults. those here for reasons other than offenses.

S1_COUNT
ASK	All Respondents
According to your records, at the end of the day on <b>[REF_DATE]</b>, how many persons had assigned beds in this facility in each of the following categories? <i>Include persons who were temporarily away (such as such as those released for medical care at a hospital), but had assigned beds on [REF_DATE_SHORT]. Please write “0” if there are NO persons in a category.</i> Under the age of 21 _______ 21 or older _______ Total _______

S1_DEFINE
ASK	If S1_COUNT (a) > 0 or missing
<b>NOTE</b>: For all remaining questions, “young persons” refers to “young persons under the age of 21 who have assigned beds” unless otherwise specified in the question.

S1_COUNTCATS

ASK

If S1_COUNT (a) > 0 or missing

At the end of the day on <b>[REF_DATE]</b>, how many young persons did this facility have for each of the following categories?

<i>Include persons who were temporarily away (such as such as those released for medical care at a hospital), but had assigned beds on [REF_DATE_SHORT]. Please write “0” if there are NO persons in a category.</i>

Young persons charged with or court adjudicated for an offense. <i>An offense is any behavior that is illegal in your state for underage persons alone or for both underage person and adults. See the Offense Codes <link>here</link> for reference.</i> INCLUDE: ANY offense that is illegal for both adults and underage persons. ANY offense that is ILLEGAL IN YOUR STATE for underage persons but not for adults. Examples are running away, truancy, incorrigibility, curfew violation, and underage liquor violations. Count persons with these behaviors here ONLY IF THE BEHAVIORS ARE ILLEGAL IN YOUR STATE. This includes those CHINS (Children in Need of Services) and PINS (Persons in Need of Services) who are here BECAUSE of an offense. ANY offense being adjudicated in juvenile or criminal court, including a probation or parole violation. EXCLUDE: Young persons who have committed one or more offenses in the past BUT are here FOR REASONS OTHER THAN OFFENSES. Young persons here BECAUSE OF REASONS OTHER THAN OFFESES, such as neglect, abuse, dependency, abandonment, behavioral/mental health problems, substance abuse problems, etc. Young persons who have run away, been truant or incorrigible, or violated curfew, if these behaviors are NOT considered illegal in your state. Young persons who are PINS (Persons in Need of Services) or CHINS (Children in Need of Services) who are here because of REASONS OTHER THAN OFFENSES.
Young persons assigned beds for other reasons INCLUDE: Young persons here for NON-OFFENSE REASONS such as neglect, abuse, dependency, abandonment, behavioral/mental health problems, substance abuse problems, or another NON-OFFENSE reason. Young persons who have committed one or more offenses in the past BUT are here FOR REASONS OTHER THAN OFFENSES. Young persons who have run away, been truant or incorrigible, or violated curfew, if these behaviors are NOT considered illegal in your state. Young persons here due to voluntary or non-offense related admissions. EXCLUDE: Young persons here BECAUSE THEY WERE CHARGED WITH OR COURT-ADJUDICATED FOR AN OFFENSE.
Total

S1_ONSITE_TREAT
ASK	If S1_COUNT (a) > 0 or missing
<b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. 10a. Does this facility provide ON-SITE RESIDENTIAL TREATMENT INSIDE this facility? Yes No

S1_ONSITE_TREAT_TYPE
ASK	If S1_ONSITE_TREAT = 1 or missing
10b. What kind of treatment is provided INSIDE this facility? <i> Select all that apply. </i> Mental health treatment Behavioral modification or therapy Substance abuse treatment Sex offender treatment Treatment for arsonists Treatment specifically for violent offenders Trauma treatment Anger management Other – Please specify:

S1_ACTIVITIES

ASK

If S1_COUNT (a) > 0 or missing

Does your facility provide each of the following activities or services for the young persons in your facility through either the facility’s own staff or by bringing in external providers? <i>Select all that apply in each row.</i>

	Provided by the facility’s staff	Provided by bringing in external providers	The facility does not provide this
Artistic opportunities (e.g., music, painting, drama)
Formal mentoring program
Recreation (e.g., team sports, playing games)
Reentry planning
Religious/Spiritual/Faith Based
Wellness (e.g., yoga, meditation)
Workforce development or vocational training

S1_ACTIVITIES_OTHER
ASK	If S1_COUNT (a) > 0 or missing
Are there any other activities or services not listed above that are provided for young persons in your facility?

S1_LOCKED
ASK	If S1_COUNT (a) > 0 or missing
19a. Are ANY young persons in this facility locked into their sleeping rooms by staff at ANY time to confine them? Yes No

S1_LOCKSITS
ASK	If S1_LOCKED = 1 or missing
In what situations are young persons locked in their sleeping rooms? <i>Select all that apply.</i> When they are out of control When they are suicidal For medical reasons other than suicide During shift changes Whenever they are in their sleeping rooms As part of a set schedule Other – Please specify:

S1_LOCKSCHED_A
ASK	If S1_LOCKSITS = 5 or missing and FORM = A
When are young persons locked in their sleeping rooms? <i>Select all that apply.</i> All of the time During the day for 2 hours or less During the day for more than 2 hours At night

S1_LOCKSCHED_B
ASK	If S1_LOCKSITS = 5 or missing and FORM = B
When are young persons locked in their sleeping rooms? <i>Select all that apply.</i> Rarely Sometimes Often Always

S1_LOCKFEATS
ASK	If S1_COUNT (a) > 0 or missing
20. Does this facility have any of the following features intended to confine young persons within specific areas? <i> Select all that apply.</i> Doors for secure day rooms that are locked by staff to confine young persons within specific areas or rooms Wing, floor, corridor, or other internal security doors that are locked by staff to confine young persons within specific areas Outside doors that are locked by staff to confine young persons within specific buildings External gates in fences or walls WITHOUT razor wire that are locked by staff to confine young persons External gates in fences or walls WITH razor wire that are locked to confine young persons Other – Please specify: The facility has none of the above features.

S1_OUTDOORLOCKED
ASK	If S1_COUNT (a) > 0 or missing
21a. Are outside doors to any buildings with living/sleeping units in this facility ever locked? Yes No

S1_OUTDOORLOCKED_REAS
ASK	If S1_OUTDOORLOCKED = 1 or missing
21b. Are outside doors to buildings with living/sleeping units in this facility locked to keep young persons inside this facility? Yes No

S1_OUTDOORLOCKED_WHEN
ASK	If S1_OUTDOORLOCKED = 1 or missing
21c. WHEN are outside doors to buildings with living/sleeping units in this facility locked? <i>Select all that apply.</i> All of the time Rarely, no set schedule During the day for 2 hours or less During the day for more than 2 hours At night

S1_SEPUNITS
ASK	If S1_COUNT (a) > 0 or missing
14a. Does this facility have one or more living/sleeping units, such as wings, floors, dorms, barracks, or cottages, for the purpose of keeping any young persons separate in housing and activities from other residents for specialized care or security? <i>Do NOT include time-out rooms, isolation rooms or infirmaries. IF THE ONLY REASON for separate housing and activities ARE SEX OR AGE, ANSWER <b>NO</b>.</i> Yes No

S1_SEPUNIT_TYPE
ASK	If S1_SEPUNITS = 1 or missing
14b. Do any of these separate living/sleeping units differ in terms any of the following ways? … <i>Select all that apply.</i> Average length of stay of young persons Physical security and/or monitoring of young persons Number of staff per young person Type of treatment program Characteristics of young persons Specialized criteria for staff selection Other? – Please specify:

S1_SEPUNIT_PURPOSE
ASK	If S1_SEPUNITS = 1 or missing
14c. What is the purpose for having separate living/sleeping units? <i>Select all that apply.</i> To provide two or more types of specialized care in separate living/sleeping units To provide a series of separate living/sleeping units with different specialized care that all young persons move through from the time they enter until the time they leave To provide two or more levels of security Some other reason – Please specify:

S1_SEPUNIT_SHARE
ASK	If S1_SEPUNITS = 1 or missing
14d. Do the separate living/sleeping units within this facility share any of the following attributes? <i>Select all that apply.</i> The same agency affiliation The same mailing address The same on-site administrators One or more staff directly caring for the young persons One or more security staff The same school rooms The same dining room at the same time The same recreational areas at the same time The same laundry services None of the above services are shared

S1_TOTBEDS
ASK	If S1_COUNT (a) > 0 or missing
22. What was the TOTAL NUMBER OF STANDARD BEDS for young persons in this facility on the night of <b>[REF_DATE]</b>? <i>Do NOT include staff beds. A single bed is one standard bed A double bunked bed is two standard beds</i> _____ Total number of standard beds

S1_MAKESHIFTBEDS
ASK	If S1_COUNT (a) > 0 or missing
23a. On the night of <b>[REF_DATE]</b>, were there ANY OCCUPIED MAKESHIFT BEDS in this facility? <i>Makeshift beds are: Roll-out mats Fold-out cots Roll-away beds Pull-out mattresses Sofas Any other beds that are put away or moved during non-sleeping hours</i> Yes No

S1_MAKESHIFTBEDS_COUNT
ASK	If S1_MAKESHIFTBEDS = 1 or missing
23b. How many makeshift beds were occupied that night? _____ Occupied makeshift beds

S1_STAFFTRAIN_REQ_B
ASK	If S1_COUNT (a) > 0 or missing and FORM = B
Which of the following training requirements are frontline supervision staff and direct care staff <b>required</b> to take before working with young persons? <i> Select all that apply.</i> Behavioral health interventions and resources Conflict de-escalation training and communication with youth Cross-gender supervision Defensive tactics and restraint techniques Gang management, identification, and prevention LGBTQ+ responsiveness Managing mentally disordered youth Professional Conduct and Ethics Staff boundaries Trauma informed care

S1_STAFFTRAIN_REQ_OTHER_B
ASK	If S1_COUNT (a) > 0 or missing and FORM = B
Are there any other training requirements not listed above that frontline supervision staff and direct care staff are <b>required</b> to take before working with young persons?

S1_STAFFTRAIN_REQ_A
ASK	If S1_COUNT (a) > 0 or missing and FORM = A
What training requirements are frontline supervision staff and direct care staff <b>required</b> to take before working with young persons?

S1_STAFFTRAIN_OFFER
ASK	If S1_COUNT (a) > 0 or missing
What additional optional training topics or domains have been <b>offered</b> to frontline supervision staff and direct care staff of young persons within the <b>past year</b>?

SECTION 2: BEHAVIORAL/MENTAL HEALTH SERVICES

S2_MHPROVIDERS

ASK

If S1_COUNT (a) > 0 or missing

For each of the following <b>behavioral/mental health providers</b>, please indicate if young persons have access to these providers as paid facility employees, contract staff, available as needed in the community, or if the behavioral/mental health providers are not available. <i>Select all that apply in each row.</i>

	Available as paid facility employees	Available as contract staff	Available as needed in the community	Not available
Psychiatrists (MDs or DOs)
Licensed clinical psychologists (PhDs)
Licensed clinical social workers or licensed mental health clinicians (e.g., persons with a master’s degree in social work)
Other, please specify

S2_SUICIDERISK
ASK	If S1_COUNT (a) > 0 or missing
1a. After arrival in this facility, are ANY young persons asked questions or administered a form which asks questions to determine risk for suicide? Yes No

S2_SUICIDERISK_FORMS
ASK	If S2_SUICIDERISK = 1 or missing
1b. What best describes the process through which young persons are asked questions or administered a form which asks questions to determine risk of suicide? <i> Select all that apply.</i> One or more questions about suicide incorporated into the medical history or intake process A form or questions designed by this facility to assess suicide risk A form or questions designed by a county or state juvenile justice system to assess suicide risk MAYSI- Full Form MAYSI- Suicide/depression module Columbia Suicide Severity Rating Scale (CSSRA/CCSSRS) V-DISC Other – Please specify:

S2_SUICIDERISK_ADMIN
ASK	If S2_SUICIDERISK = 1 or missing
<b>Important Note</b> <i> “Behavioral/Mental health professionals” </i> are limited in this questionnaire to – psychiatrists, psychologists with at least a Master’s degree in PSYCHOLOGY, and social workers with at least a Master’s in SOCIAL WORK (MSW, LCSW). <i> “Counselors” </i> in this questionnaire are persons with a Master’s degree in a field other than psychology or social work, or persons whose highest degree is a Bachelor’s in any field. 2. Who asks questions or administers a form which asks questions to determine risk of suicide? <i> Select all that apply.</i> Counselors/intake workers who have NOT been trained by behavioral/mental health professionals Counselors/intake workers who have been trained by behavioral/mental health professionals Behavioral/Mental health professionals, as defined above Medical Professionals, such as a doctor or nurse Supervision or detention officer Some other person – Please specify:

S2_SUICIDERISK_FIRST
ASK	If S2_SUICIDERISK = 1 or missing
3. When are young persons FIRST asked questions or administered a form which asks questions to determine risk of suicide? Prior to arrival Within less than 24 hours after arrival Between 24 hours and less than 7 days after arrival Seven or more days after arrival Other – Please specify:

S2_SUICIDERISK_WHO
ASK	If S2_SUICIDERISK = 1 or missing
4. Which young persons are asked questions or administered a form which asks questions to determine risk of suicide? <i> Select all that apply.</i> ALL young persons are asked questions or administered a form which asks questions to determine suicide risk Young persons who come directly from home, rather than from another facility Young persons who display or communicate suicide risk Young persons known to have prior suicide attempts Young persons for whom no behavioral/mental health care record is available Other young persons not listed above – Please specify:

S2_SUICIDERISK_REASK
ASK	If S2_SUICIDERISK = 1 or missing
5a. Are ANY young persons re-asked questions or re-administered a form which asks questions to determine risk for suicide? Yes No

S2_REASK_CONDS
ASK	If S2_SUICIDERISK_REASK = 1 or missing
5b. Which best describes the conditions under which young persons are re-asked questions or re-administered a form that asks questions to determine suicide risk? <i> Select all that apply.</i> As necessary on a case-by-case basis Systematically, based on length of stay, facility events, or negative life events (for example, after each court appearance, every time the young person re-enters the facility, after a death in the family) Other – Please specify:

S2_SUICIDERISK_LEVELS
ASK	If S1_COUNT (a) > 0 or missing
6. Does this facility assign different levels of risk to young persons based on their perceived risk of suicide? Yes No

S2_SUICIDERISK_OBS
ASK	If S1_COUNT (a) > 0 or missing
<b>NOTE:</b> The following questions ask about preventative measures taken once a young person is identified to be at risk for suicide. Please include all levels of suicide risk used by this facility, if any, when answering these questions. 7a. Are young persons who are determined to be at risk for suicide ever placed in a sleeping room or observation room that is locked or under staff security? Yes No

S2_OBS_FEATURES
ASK	If S2_SUICIDERISK_OBS = 1 or missing
7b. Which of the following best describes what happens in the sleeping room or observation room that is locked or under staff security? <i> Select all that apply.</i> Camera observation Staff checks every 5 minutes or less Staff checks every 6-10 minutes Staggering staff checks Line-of- sight supervision (direct or through glass) Staff assigned to doorway or in sleeping room/One-on-one supervision/Arms length supervision Other – Please specify:

S2_SUICIDERISK_PREVENT
ASK	If S1_COUNT (a) > 0 or missing
8. Are any of the following preventative measures taken when a young person is determined to be at risk for suicide? <i> Select all that apply.</i> No preventative measures are taken when a young person is determined to be at risk for suicide One-on-one supervision/Arms length supervision Line-of-sight supervision Special clothing to identify young persons as at risk for suicide Special clothing designed to prevent suicide attempts Restraints used to prevent suicide attempts Removal of personal items that may be used to attempt suicide Removal from the general population Hospitalization Access to family Access to books, journals, music, art, or other coping mechanisms Other – Please specify:

S2_MHSERVICES_RECEIVE
ASK	If S1_COUNT (a) > 0 or missing
<b>Note:</b> The next few questions ask about behavioral/mental health services provided at a location either <b>INSIDE</b> or <b>OUTSIDE</b> this facility. <b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. 9. Do young persons receive behavioral/mental health services other than a suicide evaluation either INSIDE or OUTSIDE this facility? <i>Behavioral/Mental health services include: evaluations and appraisals conducted by behavioral/mental health professionals to diagnose or to identify behavioral/mental health needs ongoing behavioral/mental health therapy ongoing counseling</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, this facility does not provide behavioral/mental health services

S2_MHSERVICES_COUNSEL
ASK	If S2_MHSERVICES_RECEIVE = 1, 2, 3 or missing
10a. Is ongoing COUNSELING provided for these behavioral/mental health problems provided INSIDE or OUTSIDE this facility by a COUNSELOR? <i>Counselors are limited to: persons with a Master’s degree in a field other than psychology or social work persons whose highest degree is a Bachelor’s in any field</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, ongoing counseling is not provided

S2_MHCOUNSEL_TYPE
ASK	If S2_MHSERVICES_COUNSEL = 1, 2, 3 or missing
10b. Which forms of ongoing COUNSELING for behavioral/mental health problems are provided by a COUNSELOR? <i> Select all that apply. </i> Individual counseling Group counseling Family counseling Other – Please specify:

S2_MHEVAL
ASK	If S2_MHSERVICES_COUNSEL = 1, 2, 3 or missing
11. Are ANY young persons evaluated or appraised by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS at a location INSIDE or OUTSIDE this facility? <i>Evaluations and appraisals are conducted by mental health professionals to diagnose or to identify behavioral/mental health needs. Behavioral/Mental health professionals are limited to: psychiatrists psychologists with at least a Master’s degree in PSYCHOLOGY social workers with at least a Master’s degree in SOCIAL WORK (MSW, LCSW)</i> Yes, both INSIDE and OUTSIDE this facility Yes, INSIDE this facility Yes, OUTSIDE this facility No

S2_MHEVAL_WHEN
ASK	If S2_MHEVA = 1, 2, 3 or missing
12. When are young persons evaluated or appraised by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS? <i>Select all that apply. </i> Prior to arrival Within less than 24 hours after arrival Between 24 hours and less than 7 days after arrival Seven or more days after arrival Other – Please specify:

S2_MHEVAL_WHO
ASK	If S2_MHEVALUATE = 1, 2, 3 or missing
13. Which young persons are evaluated or appraised by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS? <i>Select all that apply. </i> ALL young persons are evaluated or appraised by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS Young persons who come directly from home, rather than from another facility Young person who are ordered by the court to get an evaluation Young persons who staff identify as needing an evaluation Young persons known to have behavioral/mental health problems Young persons for whom no behavioral/mental health record is available Other – Please specify:

S2_MHTHERAPY
ASK	If S2_MHSERVICES_COUNSEL = 1, 2, 3 or missing
14a. Is ongoing THERAPY provided for behavioral/mental health problems provided to young persons by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS INSIDE or OUTSIDE this facility? <i>Behavioral/Mental health professionals are limited to: psychiatrists psychologists with at least a Master’s degree in PSYCHOLOGY social workers with at least a Master’s degree in SOCIAL WORK (MSW, LCSW)</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, ongoing THERAPY is not provided

S2_MHTHERAPY_TYPE
ASK	If S2_MHTHERAPY = 1, 2, 3 or missing
14b. Which forms of ongoing THERAPY for behavioral/mental health problems are provided by BEHAVIORAL/MENTAL HEALTH PROFESSIONALS? <i> Select all that apply. </i> Individual therapy Group therapy Family therapy Other – Please specify:

S2_MHTHERAPY_POLICY
ASK	If S2_MHTHERAPY = 1, 2, 3 or missing
14c. Which of the following best describes this facility policy on providing THERAPY by a BEHAVIORAL/MENTAL HEALTH PROFESSIONALS INSIDE or OUTSIDE this facility? <i> Select ONLY ONE response. </i> All young persons receive some therapy at some point during their stay Young persons receive therapy only as needed on a case-by-case basis Other – Please specify:

S2_MHSEPARATE_SLEEP
ASK	If S1_COUNT (a) > 0 or missing
16a. Are there one or more special living/sleeping unit(s) in this facility reserved just for young persons with behavioral/mental health problems that are separate from other living/sleeping units? Yes No

S2_MHSLEEP_FEATURES
ASK	If S2_MHSEPARATE_SLEEP = 1 or missing
16b. Do any of these special living/sleeping units reserved just for young persons with behavioral/mental health problems differ from the other living/sleeping units in any of the following ways? – <i> Select all that apply. </i> Average length of stay Physical security and/or monitoring of young persons Number of staff per young persons Type of treatment program Characteristics of young persons Specialized criteria for staff selection Specialized curriculum of treatment for the residents of these units Other – Please specify:

S2_SEXOFFEND_TREATPROG
ASK	If S1_COUNT (a) > 0 or missing
17a. Is there a specialized SEX OFFENDER treatment program located inside this facility? Yes No

S2_SEXOFFEND_PROGFEAT
ASK	If S2_SEXOFFEND_TREATPROG = 1 or missing
17b. Are any of the following provided to young persons charged with or adjudicated for a sex offense? <i> Select all that apply. </i> A curriculum of treatment designed specifically for sex offenders Individual therapy/counseling specifically for sex offenders Group therapy in which all members of the group are sex offenders Family therapy/counseling specifically for sex offenders Other – Please specify:

S2_SEXOFFEND_SLEEP
ASK	If S1_COUNT (a) > 0 or missing
18. Are there one or more special living/sleeping units reserved just for sex offenders that are separate from other living/sleeping units? Yes No

S2_MHSTATUS_RELEASE
ASK	If S1_COUNT (a) > 0 or missing
19a. Upon a young person’s departure from this facility, is information regarding their behavioral/mental health status, services, and/or needs communicated to the young persons’ new placement or residence? Yes No

S2_MHSTATUS_RELEASE_SHARE
ASK	If S2_MHSTATUS_RELEASE = 1 or missing
19b. For which young persons is this information shared? <i> Select all that apply. </i> All young persons that depart from the facility Young persons being placed in other juvenile justice facilities, including halfway houses, shelters or other transition homes Young persons returning to the community under juvenile justice supervision through probation, parole, or aftercare Young persons returning to the community (their homes, independent living, foster care, or another type of guardian’s care) without further juvenile justice supervision Young persons being placed in adult criminal justice facilities (prisons, jails) Young persons going to another living or placement situation – Please explain:

SECTION 2b: MEDICAL SERVICES

S2b_MEDPROVIDERS

ASK

If S1_COUNT (a) > 0 or missing

For each of the following <b>medical providers</b>, please indicate if young persons have access to these providers as paid facility employees, contract staff, available as needed in the community, or if the medical providers are not available. <i>Select all that apply in each row.</i>

	Available as paid facility employee	Available as contract staff	Available as needed in the community	Not available
Physicians (MDs or DOs)
Dentists (DDS)
Nurse practitioners (NPs) or physician assistants (PAs)
Registered nurses (RNs)
Licensed practical nurses (LPNs) or licensed vocational nurses (LVNs)
Certified nursing assistants, nursing assistants, medication technicians or medication aides

S2b_EXAMS

ASK

If S1_COUNT (a) > 0 or missing

<b>INSIDE</b> refers to any location on the facility grounds.

<b>OUTSIDE</b> refers to any location in the community or off facility grounds.

Do ANY young persons receive the following examinations by a physician (MD or DO), nurse practitioner (NP), or physician assistant (PA) at a location either INSIDE or OUTSIDE of this facility?

	Yes, provided both INSIDE and OUTSIDE this facility	Yes, provided only INSIDE this facility	Yes, provided only OUTSIDE this facility	No, not provided
Physical Examination
Dental Examination
Vision Examination

S2b_VACCINES
ASK	If S1_COUNT (a) > 0 or missing
When a medical provider orders vaccinations for ANY young persons, do the young persons receive the vaccination at a location either INSIDE or OUTSIDE of this facility? Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No

S2a_PSYCHOTROPICMEDS
ASK	If S1_COUNT (a) > 0 or missing
15. Do MEDICAL health professionals INSIDE or OUTSIDE this facility prescribe and/or monitor psychotropic medication for young persons? Yes, both INSIDE and OUTSIDE this facility Yes, INSIDE this facility Yes, OUTSIDE this facility No, psychotropic medications are not prescribed

S2b_FEMALES
ASK	If S1_COUNT (a) > 0 or missing
Does this facility house ANY female young persons? Yes No

S2b_EXAMS_GYNE
ASK	If S2b_FEMALES = 1 or missing
Do ANY female young persons receive a gynecological examination by a physician (MD or DO), nurse practitioner (NP), or physician assistant (PA) at a location either INSIDE or OUTSIDE of this facility? <i>A gynecological examination involves the medical provider gathering a medical history regarding reproductive health and sexual behavior and conducting a pelvic and breast exam.</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No

S2b_PREG
ASK	If S2b_FEMALES = 1 or missing
During the year between <b>[YEAR_REF_START]</b> and <b>[YEAR_REF_END]</b>, were ANY female young persons in this facility known by facility staff to be pregnant? Yes No

S2b_PREGCOUNT
ASK	If S2b_PREG = 1 or missing
How many female young persons in this facility were pregnant between <b>[YEAR_REF_START]</b> and <b>[YEAR_REF_END]</b>? _____ Number of pregnant female young persons

SECTION 3: EDUCATIONAL SERVICES

S3_EDUCEVAL
ASK	If S1_COUNT (a) > 0 or missing
<b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. 1. After arrival in this facility, are ANY young persons evaluated to determine their educational grade levels and their educational needs at a location either INSIDE or OUTSIDE this facility? Yes No

S3_EDUCEVAL_WHEN
ASK	If S3_EDUCEVAL = 1 or missing
2. After arrival in this facility, when are young persons FIRST evaluated to determine their educational grade level? <i> Select all that apply. </i> Within less than 24 hours after arrival Between 24 hours and less than 7 days after arrival Seven or more days after arrival Other – Please specify:

S3_EDUCEVAL_METHODS
ASK	If S3_EDUCEVAL = 1 or missing
3. Which of the following methods are used to evaluate young persons to determine their educational grade levels and their educational needs? <i> Select all that apply. </i> Review of previous academic records Interview with an education specialist Interview with teacher or other school staff Administration of one or more written or computerized tests Interview with an intake or admissions counselor Interview with guidance counselor Other – Please specify:

S3_EDUCEVAL_WHO
ASK	If S3_EDUCEVAL = 1 or missing
4. Which young persons are evaluated to determine their educational grade levels and their educational needs? <i> Select all that apply. </i> ALL young persons are evaluated Young persons who come directly from home, rather than from another facility Young persons whom the staff identify as needing an assessment Young persons for whom no educational record is available Young persons with known educational problems Other young persons not listed above – Please specify:

S3_EDUCEVAL_DISCHARGE
ASK	If S1_COUNT (a) > 0 or missing
5. As a part of the DISCHARGE process from this facility, are ANY young persons evaluated to determine their educational grade levels and their educational needs? Yes No

S3_EDUCEVAL_DISCHARGE_WHO
ASK	If S3_EDUCEVAL_DISCHARGE = 1 or missing
6. Which young persons are evaluated to determine their educational grade levels and their educational needs as part of the DISCHARGE process from this facility? <i> Select all that apply. </i> ALL young persons are evaluated Young persons going home or to live on their own Young persons who have been at this facility long enough to demonstrate a change in academic performance Young persons who have not yet earned a high school diploma or equivalent (GED) Young persons who have not yet earned a GED As many young persons as the educational specialists have time to evaluate Other – Please specify:

S3_EDUC_RECEIVE
ASK	If S1_COUNT (a) > 0 or missing
7a. Do ANY young persons attend school or receive teacher instruction at a location either INSIDE or OUTSIDE this facility? Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, educational services are not provided to young persons

S3_EDUC_RECEIVE_WHO
ASK	If S3_EDUC_RECEIVE = 1, 2, 3 or missing
7b. Which young persons attend school or receive teacher instruction? <i> Select all that apply. </i> ALL young persons attend school or receive teacher instruction Young persons who have not completed high school or their GED Young persons with special needs for remedial education Young persons who have been in the facility long enough to receive educational services Young persons who are required by the state to attend school because of their age Young persons assigned beds in special living/sleeping units – Please specify unit type: Other – Please specify:

S3_EDUC_PROVIDE
ASK	If S3_EDUC_RECEIVE = 1, 2, 3 or missing
8. Which of the following educational services are provided to young persons at a location either INSIDE or OUTSIDE this facility? <i> Select all that apply. </i> Elementary-level education Middle school-level education High school-level education Special education GED preparation GED testing Post-high school education or post-high school correspondence courses Vocational/technical education Life skills training Other – Please specify:

S3_EDUC_PROVIDE_HRS
ASK	If S3_EDUC_RECEIVE = 1, 2, 3 or missing
9a. How many hours per WEEK do young persons attend school or receive teacher instruction during the scheduled academic school year at a location either INSIDE or OUTSIDE this facility? _____ INSIDE facility instructional hours per WEEK _____ OUTSIDE facility instructional hours per WEEK

S3_EDUC_PROVIDE
ASK	If S3_EDUC_RECEIVE = 1, 2, 3 or missing
9b. How many months per YEAR do young persons attend school or receive teacher instruction at a location either INSIDE or OUTSIDE this facility? _____ INSIDE facility instructional months per YEAR _____ OUTSIDE facility instructional months per YEAR

S3_EDUCSTATUS_RELEASE
ASK	If S3_EDUC_RECEIVE = 1, 2, 3 or missing
10a. Upon a young person’s departure from this facility, is information regarding their educational status, services, and/or needs communicated to the young persons’ new placement or residence? Yes No

S3_EDUCSTATUS_RELEASE_SHARE
ASK	If S3_EDUCSTATUS_RELEASE = 1 or missing
10b. For which young persons is this information shared? <i> Select all that apply. </i> All young persons that depart from the facility Young persons being placed in other juvenile justice facilities, including halfway houses, shelters or other transition homes Young persons returning to the community under juvenile justice supervision through probation, parole, or aftercare Young persons returning to the community (their homes, independent living, foster care, or another type of guardian’s care) without further juvenile justice supervision Young persons being placed in adult criminal justice facilities (prisons, jails) Young persons going to another living or placement situation – Please explain:

SECTION 4: SUBSTANCE ABUSE SERVICES

S4_SUBSEVAL
ASK	If S1_COUNT (a) > 0 or missing
1a. After arrival in this facility, are ANY young persons evaluated to determine whether they have substance abuse problems? <i>Substance abuse problems include problems with drugs and/or alcohol. </i> Yes No

S4_SUBSEVAL_METHODS
ASK	If S4_SUBSEVAL = 1 or missing
1b. Which of the following methods are used to evaluate young persons after arrival in this facility to determine whether they have substance abuse problems? <i> Select all that apply. </i> Visual observation Standardized self-report instruments, such as the SASSI, JASI, ACDI, ASI MAYSI Self-report check list inventory which asks about substance use and abuse A staff-administered series of questions which asks about substance use and abuse Other – Please specify: None of these methods are used

S4_SUBSEVAL_WHEN
ASK	If S4_SUBSEVAL = 1 or missing
2. When are young persons FIRST evaluated to determine whether they have substance abuse problems? Prior to arrival Within less than 24 hours after arrival Between 24 hours and less than 7 days after arrival Seven or more days after arrival Other – Please specify:

S4_SUBSEVAL_ALL
ASK	If S4_SUBSEVAL = 1 or missing
3a. Are ALL young persons evaluated to determine whether they have substance abuse problems? Yes No

S4_SUBSEVAL_WHO
ASK	If S4_SUBSEVAL_ALL = 2 or missing
3b. After arrival in this facility, which young persons are evaluated for substance abuse problems? <i> Select all that apply. </i> Young persons charged with or adjudicated for a drug or alcohol-related offense Young persons identified by the court or a probation officer as potentially having substance abuse problems Young persons identified by facility staff as potentially having substance abuse problems Other young persons not listed above – Please specify:

S4_URINETEST
ASK	If S1_COUNT (a) > 0 or missing
4a. Are ANY young persons required to provide urine FOR DRUG ANALYSIS after arrival IN THIS FACILITY? Yes No

S4_URINETEST_CIRCUM

ASK

If S4_URINETEST = 1 or missing

4b. Which statements below describe the circumstances under which young persons are required to provide urine FOR DRUG ANALYSIS after arrival in this facility? <i> Select all that apply in each row. </i>

PERSONS PROVIDING URINE SAMPLE	CIRCUMSTANCES OF TESTING
	After initial arrival in this facility (1)	Each time young persons reenter the facility during their stay (2)	At randomly scheduled times (3)	When drug use is suspected or drug is present (4)	At the request of the court or probation officer (5)
a. Young persons who are suspected of recent drug or alcohol use
b. Young persons with substance abuse problems
c. ALL young persons

S4_NOTE
ASK	If S1_COUNT (a) > 0 or missing
<b>NOTE:</b> The next few questions ask about substance abuse services provided at a location either <b>INSIDE</b> and/or <b>OUTSIDE</b> this facility. <b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. <b>IMPORTANT INSTRUCTIONS</b> Substance abuse services include: developing a substance abuse treatment plan assigning a case manager to oversee substance abuse treatment assigning young persons to special living units just for those with substance abuse problems ongoing substance abuse therapy or counseling substance abuse education Substance abuse treatment professionals are limited in this census to: CERTIFIED substance abuse or addictions counselors psychiatrists psychologists with at least a Master’s degree in PSYCHOLOGY social workers with at least a Master’s degree in SOCIAL WORK (MSW, LCSW) Counselors who are NOT substance abuse treatment professionals are limited to: persons with a Master’s degree in a field other than psychology or social work or whose highest degree is a Bachelor’s in any field AND do NOT hold a certification in substance abuse or addiction counseling

S4_SUBABUSE_RECEIVE
ASK	If S1_COUNT (a) > 0 or missing
5. Do ANY young persons receive substance abuse services INSIDE or OUTSIDE this facility other than urinalysis or a substance abuse screening? Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, this facility does not provide substance abuse services

S4_SUBABUSE_SERVICE
ASK	If S4_SUBABUSE_RECEIVE = 1, 2, 3 or missing
6. Which of the following SUBSTANCE ABUSE services are provided INSIDE or OUTSIDE this facility? <i>Select all that apply. </i> Substance abuse education Ongoing substance abuse therapy or counseling Assignment of a case manager to oversee substance abuse treatment Development of a treatment plan to specifically address substance abuse problems Special living units in which all young persons have substance abuse offenses and/or problems None of these services are offered

S4_SUBABUSE_GROUP
ASK	If S4_SUBABUSE_RECEIVE = 1, 2, 3 or missing
7. Which of the following self-led, self-help groups are provided INSIDE or OUTSIDE this facility? <i>Select all that apply. </i> Alcoholics Anonymous or other related groups Narcotics Anonymous or other related groups Other – Please specify: No self-led, self-help groups are provided

S4_SUBABUSE_THERAPY
ASK	If S4_SUBABUSE_RECEIVE = 1, 2, 3 or missing
9a. Is ongoing THERAPY for substance abuse problems provided to young persons INSIDE or OUTSIDE this facility by a SUBSTANCE ABUSE TREATMENT PROFESSIONAL? <i>Substance abuse treatment professionals are limited to: CERTIFIED substance abuse/addictions counselors psychiatrists psychologist with a least a Master’s degree in psychology Social workers with a Master’s degree in SOCIAL WORK (MSW, LCSW)</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, ongoing THERAPY for substance abuse problems is not provided

S4_SUBABUSE_THERAPY_TYPE
ASK	If S4_SUBABUSE_THERAPY = 1, 2, 3 or missing
9b. Which forms of ongoing THERAPY for substance abuse problems are provided INSIDE or OUTSIDE this facility to young persons by a SUBSTANCE ABUSE TREATMENT PROFESSIONAL? <i>Select all that apply.</i> Individual therapy Group therapy Family therapy None of these are provided

S4_SUBABUSE_THERAPY_POLICY
ASK	If S4_SUBABUSE_THERAPY = 1, 2, 3 or missing
9c. Which of the following best describes this facility’s policy on providing ongoing therapy for substance abuse problems INSIDE or OUTSIDE this facility to persons by a SUBSTANCE ABUSE TREATMENT PROFESSIONAL? All young persons receive specialized therapy or counseling for substance abuse problems Young persons receive specialized therapy or counseling for substance abuse problems only as needed on a case-by-case basis Other – Please specify:

S4_SUBABUSE_COUNSEL
ASK	If S4_SUBABUSE_RECEIVE = 1, 2, 3 or missing
8a. Is ongoing COUNSELING for substance abuse problems provided to young persons INSIDE or OUTSIDE this facility by a COUNSELOR who is NOT a substance abuse treatment professional? <i>Counselors who are NOT substance abuse treatment professionals are: persons with a Master’s degree in a field other than psychology or social work or persons whose highest degree is a Bachelor’s in any field AND do NOT hold a certification in substance abuse or addiction counseling</i> Yes, provided both INSIDE and OUTSIDE this facility Yes, provided INSIDE this facility Yes, provided OUTSIDE this facility No, ongoing COUNSELING for substance abuse problems is not provided

S4_SUBABUSE_COUNSEL_TYPE
ASK	If S4_SUBABUSE_COUNSEL = 1, 2, 3 or missing
8b. Which forms of ongoing COUNSELING for substance abuse problems are provided INSIDE or OUTSIDE this facility to young persons by a COUNSELOR who is NOT a substance abuse treatment professional? <i>Select all that apply.</i> Individual counseling Group counseling Family counseling None of these are provided

S4_SUBABUSE_RELEASE
ASK	If S4_SUBABUSE_THERAPY = 1, 2, 3 or missing
10a. Upon a young person’s departure from this facility, is information regarding their substance abuse status, services and/or needs communicated to the young persons’ new placement or residence? Yes No

S4_SUBABUSE_RELEASE_SHARE
ASK	If S4_SUBABUSE_RELEASE = 1 or missing
10b. For which young persons is this information shared? <i>Select all that apply.</i> All young persons that depart from the facility Young persons being placed in other juvenile justice facilities, including halfway houses, shelters or other transition homes Young persons returning to the community under juvenile justice supervision through probation, parole, or aftercare Young persons returning to the community (their homes, independent living, foster care, or another type of guardian’s care) without further juvenile justice supervision Young persons being placed in adult criminal justice facilities (prisons, jails) Young persons going to another living or placement situation – Please specify:

SECTION 5: THE LAST MONTH

S5_UNAUTHDEPART
ASK	If S1_COUNT (a) > 0 or missing
<b>IMPORTANT INSTRUCTIONS</b> The following items ask you to answer questions about different events that may have occurred at this facility over a 30-day period. The 30-day REFERENCE PERIOD for this section covers the time between the beginning of the day, [MONTH_REF_START] and the end on the day on [MONTH_REF_END]. 1. During the month of <b>[MONTH_REF_YR]</b>, were there ANY UNAUTHORIZED DEPARTURES of any young persons? <i> An “unauthorized departure” includes any incident in which a young person leaves without staff permission or approval for more than 10 minutes from: The physical security perimeter of the facility The mandatory supervision of a staff member when there is no physical security The mandatory supervision of transportation staff Any other approved areas </i> Yes No

S5_ERTRANSPORT
ASK	If S1_COUNT (a) > 0 or missing
2a. During the month of <b>[MONTH_REF_YR]</b>, were ANY young persons transported to a hospital emergency room by facility staff, transportation staff, or by an ambulance? Yes No

S5_ERTRANSPORT_REASON
ASK	If S5_ERTRANSPORT =1 or missing
2b. For what reason(s) were the young persons transported to a hospital emergency room DURING THIS 30 DAY PERIOD in [MONTH_REF]? <i>Select all that apply.</i> Sports-related injury Work or chore-related injury An injury that resulted from interpersonal conflict between one or more young persons, not including a sports-related injury An injury that resulted from interpersonal conflict between a young person and a non-resident (including staff, visitors, or persons from the community). Illness Pregnancy complications Labor and delivery Suicide attempt A non-emergency injury or illness that occurred when no physical health professional was available at the facility or on call A non-emergency injury or illness that occurred when no doctor’s appointment could be obtained in the community Other – Please specify:

S5_RESTRAIN
ASK	If S1_COUNT (a) > 0 or missing
3. During the month of <b>[MONTH_REF_YR]</b>, were ANY young persons restrained by facility staff with a mechanical restraint, excluding use during transportation to and from this facility? <i>Mechanical restraints include handcuffs, leg cuffs, waist bands, leather straps, restraining chairs, strait jackets or other mechanical devices. </i> Yes No

S5_LOCKED_BEHAVE
ASK	If S1_COUNT (a) > 0 or missing
4. During the month of <b>[MONTH_REF_YR]</b>, were ANY young persons locked for more than four hours alone in an isolation, seclusion, or sleeping room to regain control of their unruly behavior? <i>Answer NO if: Young persons were locked in their sleeping rooms as part of the facility routine OR Young persons were locked in their rooms ONLY for purposes of quarantine, suicide watch, facility-wide lockdown, or self-requested seclusion</i> Yes No

S5_PHYSHEALTH
ASK	If S1_COUNT (a) > 0 or missing
<b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. 5a. During the month of <b>[MONTH_REF_YR]</b>, were there any instances in which this facility was unable to obtain PHYSICAL HEALTH CARE (at locations either inside or outside of this facility) for any young persons with a physical health complaint or need for physical health care (both urgent and non-urgent)? Yes No, this facility does not provide or broker physical health care services (except through contacting emergency services like ambulances) No, there were no such instances

S5_PHYSHEALTH_REAS
ASK	If S5_PHYSHEALTH = 1 or missing
5b. What reasons prevented PHYSICAL HEALTH CARE from being obtained for young persons in need? <i> Select all that apply.</i> Long-term shortages of physical health care staffing at this facility Short-term, temporary shortages of physical health care staffing at this facility Shortages, temporary interruptions in, or absence of contracts with physical health care providers in the community Shortages in line staff or other direct care staff to fill in for staff who accompany young persons to health care services Shortages in transportation staff or vehicles Single or multiple instances of facility lock downs or other security issues that prevented health care “services as usual” from occurring <i>for all young persons</i> in the facility or all <i>young persons in specific units or wings</i> of this facility. Single or multiple instances of security risks for <i>individual</i> young persons that prevented health care “services as usual” from occurring Planned and/or unplanned requirements to appear before the court or to meet with legal counsel Other reasons – Please specify:

S5_MENTHEALTH
ASK	If S1_COUNT (a) > 0 or missing
6a. During the month of <b>[MONTH_REF_YR]</b>, were there any instances in which this facility was unable to secure obtain BEHAVIORAL/MENTAL HEALTH CARE (at locations either inside or outside of this facility) for any young persons with a behavioral/mental health complaint or need for behavioral/mental health care (both urgent and non-urgent)? Yes No, this facility does not provide or broker behavioral/mental health care services (except through contacting emergency services like ambulances) No, there were no such instances

S5_MENTHEALTH_REAS
ASK	If S5_MENTHEALTH = 1 or missing
6b. What reasons prevented BEHAVIORAL/MENTAL HEALTH CARE from being obtained for young persons in need? <i> Select all that apply.</i> Long-term shortages of behavioral/mental health care staffing at this facility Short-term, temporary shortages of behavioral/mental health care staffing at this facility Shortages, temporary interruptions in, or absence of contracts with behavioral/mental health care providers in the community Shortages in line staff or other direct care staff to fill in for staff who accompany young persons to behavioral/mental health care services Shortages in transportation staff or vehicles Single or multiple instances of facility lock downs or other security issues that prevented behavioral/mental health care “services as usual” from occurring <i>for all young persons</i> in the facility or all <i>young persons in specific units or wings</i> of this facility. Single or multiple instances of security risks for <i>individual</i> young persons that prevented behavioral/mental health care “services as usual” from occurring Planned and/or unplanned requirements to appear before the court or to meet with legal counsel Other reasons – Please specify:

S5_EDUC
ASK	If S1_COUNT (a) > 0 or missing
7a. During the month of <b>[MONTH_REF_YR]</b>, were there any instances in which this facility was unable to obtain EDUCATIONAL INSTRUCTION (at locations either inside or outside of this facility) for any young persons who are required by state statute to receive educational instruction? <i> NOTE: Do not consider planned breaks from educational instruction (such as summer recess or religious holidays) as an inability to provide educational instruction. </i> Yes No, this facility does not provide, broker, or arrange through public schools in the community any educational instruction No, there were no such instances

S5_EDUC_REAS
ASK	If S5_EDUC = 1 or missing
7b. What reasons prevented EDUCATIONAL INSTRUCTION from being obtained for young persons in need? Select all that apply.</i> Long-term shortages of educational instructors at this facility Short-term, temporary shortages of educational instructors at this facility Shortages, temporary interruptions in, or absence of contracts with educational instruction service providers in the community Shortages in line staff or other direct care staff to fill in for staff who accompany young persons to educational instruction Shortages in transportation staff or vehicles Single or multiple instances of facility lock downs or other security issues that prevented educational “instruction services as usual” from occurring <i>for all young persons</i> in the facility or all <i>young persons in specific units or wings</i> of this facility Single or multiple instances of security risks for <i>individual</i> young persons that prevented educational “instruction as usual” from occurring Planned and/or unplanned requirements to appear before the court or to meet with legal counsel Other reasons – Please specify:

S5_SUBABUSE
ASK	If S1_COUNT (a) > 0 or missing
8a. During the month of <b>[MONTH_REF_YR]</b>, were there any instances in which this facility was unable to secure obtain SUBSTANCE ABUSE SERVICES (at locations either inside or outside of this facility) for any young persons with a substance use or abuse complaint or need for substance abuse services (both urgent and non-urgent)? Yes No, this facility does not provide or broker substance abuse services (except through contacting emergency services like ambulances) No, there were no such instances

S5_SUBABUSE_REAS;
ASK	If S5_SUBABUSE = 1 or missing
8b. What reasons prevented SUBSTANCE ABUSE SERVICES from being secured obtained for young persons in need? <i> Select all that apply. </i> Long-term shortages of substance abuse service staffing at this facility Short-term, temporary shortages of substance abuse service staffing at this facility Shortages, temporary interruptions in, or absence of contracts with substance abuse service providers in the community Shortages in line staff or other direct care staff to fill in for staff who accompany young persons to substance abuse services Shortages in transportation staff or vehicles Single or multiple instances of facility lock downs or other security issues that prevented substance abuse “services as usual” from occurring <i>for all young persons</i> in the facility or all <i>young persons in specific units or wings</i> of this facility. Single or multiple instances of security risks for <i>individual</i> young persons that prevented substance abuse “services as usual” from occurring Planned and/or unplanned requirements to appear before the court or to meet with legal counsel Other reasons – Please specify:

SECTION 6: THE LAST YEAR

S6_DEATHS
ASK	If S1_COUNT (a) > 0 or missing
<b>NOTE:</b> The next few questions ask about deaths of young persons at locations either <b>INSIDE and/or OUTSIDE</b> this facility during the period between [YEAR_REF_START] and [YEAR_REF_END]. <b>INSIDE</b> refers to any location on the facility grounds. <b>OUTSIDE</b> refers to any location in the community or off facility grounds. 1. During the YEAR between <b>[YEAR_REF_START]</b> and <b>[YEAR_REF_END]</b>, did ANY young persons die while assigned a bed at this facility at a location either INSIDE or OUTSIDE of this facility? Yes No

S6_DEATHS_COUNT
ASK	If S6_DEATHS = 1 or missing
2. How many young persons died while assigned beds at this facility during the year between [YEAR_REF_START] and [YEAR_REF_END]? _____ Person(s)

S6_DEATHS
ASK	Loop 1: If S6_DEATHS_COUNT > 0 Loop 2: If S6_DEATHS_COUNT > 1 Loop 3: If S6_DEATHS_COUNT > 2
3. Please answer the questions below for the (if S6_DEATHS_COUNT > 1 and loop = 1: first; if loop = 2: second; if loop = 3: third) death that occurred during the period between <b>[YEAR_REF_START]</b> and <b>[YEAR_REF_END]</b>. (if S6_DEATHS_COUNT > 1 and loop = 1: If you reported more than one death, this page will repeat until information for all decedents has been entered.) Cause of death Illness/natural causes (excluding AIDS) Injury suffered prior to placement here AIDS Suicide Homicide or manslaughter by another resident Homicide or manslaughter by non-resident(s) Accidental death Coronavirus (COVID-19) Other, please specify Location of death Inside this facility Outside this facility Age at death (in years) Sex assigned at birth Male Female Race White, not of Hispanic origin Black or African American, not of Hispanic origin Hispanic or Latino (i.e. Mexican, Puerto Rican, Cuban, Central or South American, or other Spanish culture or origin, regardless of race) American Indian/Alaska Native, not of Hispanic origin Asian, not of Hispanic origin Native Hawaiian or other Pacific Islander, not of Hispanic origin Two or More Races, not of Hispanic origin (specify) Date of admission to facility Date of death

S6_FEAS_ETHNICITY
ASK	If S1_COUNT (a) > 0 or missing
Does your facility document the Hispanic ethnicity of a young person separate from his/her race, such that you would be able to report both the Hispanic ethnicity and the race(s) for each young person in your facility? <i>For example, Hispanic and Black, or Non-Hispanic and Black.</i> Yes No

S6_FEAS_RACE
ASK	If S1_COUNT (a) > 0 or missing
Does your facility document all races of a young person who identifies as two or more races, such that you would be able to report all races associated with each young person in your facility? Yes No

S2a_FEAS_RACEETH_HOW
ASK	If S1_COUNT (a) > 0 or missing
How is race/ethnicity information determined? <i>Select all that apply</i> Race/ethnicity are self-reported by youth Race/ethnicity is determined by staff Race/ethnicity is obtained from the referral source (e.g., Juvenile court) Other, please specify

S6_FEAS_GENDERID
ASK	If S1_COUNT (a) > 0 or missing
Does your facility document gender identity of all young persons, such that you would be able to report both the sex assigned at birth and the self-reported gender identity for each young person in your facility? <i>For example, male and transgender male to female.</i> Yes No

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ELIGIBILITY
ASK	If S1_COUNT (c) = 0 or S1_COUNT (a) =0
Based on your prior answer, what was the reason there was no one (if S1_COUNT (a) =0: under 21) with assigned beds in your facility? Facility Permanently Closed – Specify reason and date of closure Facility Temporarily Closed – Specify reason and reopen date (if known) Adult Only Facility – Specify when facility stopped holding juvenile offenders Other – Specify

BURDEN_ESTIMATE
ASK	All Respondents
Thank you for participating in the 2021 JRFC pilot test. To help inform future JRFC data collection efforts, we would like to understand more about your experience filling out this questionnaire. About how many hours did it take you to complete this questionnaire? <i>Please include any time you spent gathering the necessary information.</i>

COMMENTS
ASK	All Respondents
Please provide any comments you have about the data submitted on this form. Click the ‘Submit Data’ button below to finalize your survey. Once data has been submitted you will be locked out of the survey an unable to make any changes. [button-Previous] [button-<b>Submit Data</b>]

THANKYOU
ASK	All Respondents
Thank you for electronically submitting the 2021 Juveniles Residential Facility Census Pilot Study questionnaire. If you have any questions, please contact 2021 JRFC Pilot Study help desk staff at [phone] or [email].