OMB 0970-0564 [valid through MM/DD/2026]
(Revised: 3/16/2022)
Staff Questionnaire – Clinician/Lead Clinician – Unlicensed Facility (UF) Quarterly Health and Safety Visit
Interview Details |
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Program Name: |
Past and Current Position(s) at Program:
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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.
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NOTES |
Tell me about your role and main responsibilities as a clinician.
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Tell me about your educational background and how you ended up working as a clinician here.
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What is your typical caseload?
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Do you have any concerns related to the confidentiality of mental health services? (i.e. designated confidential space, confidential record management system) If so, please describe. |
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What approach do you implement in providing individual and group counseling sessions for UCs?
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What does trauma-informed care mean to you?
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What are the things that you love/enjoy about your job? What are the challenges you face in your job?
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What formal/informal trainings have you received since working here?
(Lead Clinician) Do you have a system to assess ongoing staff training needs?
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How does the program handle behavioral challenges among UCs? How effective do you think the behavior management system is?
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Do you have any concerns about the treatment of UCs in care?
Do you have concerns about any particular staff members (any staff members you think should NOT be working with UC)?
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If a UC in care is presenting with mental health concerns that warrant additional services, how does the program respond?
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How does the clinical team collaborate and communicate with other departments?
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What is the program’s plan for dealing with a mental health emergency?
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(Lead Clinician) Do you have enough input and resources to make changes to improve mental health services at the program?
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What general recommendations do you have to strengthen the program? What improvements would you put in place?
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What recommendations do you have for ORR that I can take back to share with our headquarter teams?
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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 clinicians and lead clinicians 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].
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Poole, Laura (ACF) (CTR) |
File Modified | 0000-00-00 |
File Created | 2024-07-26 |