Form M-11A-UF Form M-11A-UF Program Director Questionnaire

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

(Revised: 3/16/2022)

Staff Questionnaire – Program Director/Assistant Program Director – 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 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
Provide a general overview of how your program is doing. What do you see as some of the strengths of your program? What are some of the challenges?
Tell me about your role and main responsibilities. Which staff members do you supervise directly? How do the lines of communication work at the program?
How is ORR P&P and updates to the P&P communicated to program staff? How often do you meet with staff? All staff? Individual teams?
Does the program have a system to assess ongoing staff training needs? Have you identified any training topics that you would like your staff to take?
What does trauma-informed care mean to you? Describe how the program delivers trauma-informed care to UCs? (This is a chance to explore how the program is currently implementing trauma-informed care at the organizational level. Does the program need additional resources/tools to effectively put in place trauma-informed practices and techniques?
Explain the procedures currently in place to monitor and evaluate program operations. How do you detect non-compliance with ORR P&P? How do you detect non-compliance with federal/state/local regulations? Do you feel like this process is effective? Do you feel like they need to be improved or changed?
Describe actions taken when noncompliance is detected and provide examples (staff conduct, reporting, etc.)
How does the program incorporate input from minors and staff to assess the program? How does the program incorporate information collected through ongoing self-monitoring (e.g. weekly case reviews, routine staff meetings) to assess the program?
How is the program’s budget? Are there sufficient funds to provide for UC? Does the program have sufficient funds to meet all ORR requirements?
How would you improve the program?
What recommendations do you have that I bring back to share with ORR headquarters? Is there anything that you would like to ask or discuss, that was not previously mentioned?

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 program directors and assistant program directors 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].