Program Staff Questionnaires (Form M-11A-K) - Respondents

Monitoring and Compliance for Office of Refugee Resettlement (ORR) Care Provider Facilities

OMB: 0970-0564

IC ID: 245604

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0564 can be found here:

Documents and Forms

Document Name Document Type
Form Form M-11A Program Staff Questionnaires (Form M-11A-K) - Respondents Form and Instruction
Form M-11A Program Director Questionnaire 29 - Program Director Questionnaire (Form M-11A).docx Form and Instruction
Form M-11B LTFC Program Director Questionnaire 30 - LTFC Program Director Questionnaire (Form M-11B).docx Form and Instruction
Form M-11C Clinician Questionnaire 31 - Clinician Questionnaire (Form M-11C).docx Form and Instruction
Form M-11D LTFC Clinician Questionnaire 32 - LTFC Clinician Questionnaire (Form M-11D).docx Form and Instruction
Form M-11E Case Manager Questionnaire 33 - Case Manager Questionnaire (Form M-11E).docx Form and Instruction
Form M-11F LTFC Case Manager Questionnaire 34 - LTFC Case Manager Questionnaire (Form M-11F).docx Form and Instruction
Form M-11G Education Staff Questionnaire 35 - Education Staff Questionnaire (Form M-11G).docx Form and Instruction
Form M-11H LTFC Educational Staff Questionnaire 36 - LTFC Educational Staff Questionnaire (Form M-11H).docx Form and Instruction
Form M-11I Medical Coordinator Questionnaire 37 - Medical Coordinator Questionnaire (Form M-11I).docx Form and Instruction
Form M-11J Youth Care Worker Questionnaire 38 - Youth Care Worker Questionnaire (Form M-11J).docx Form and Instruction
Form M-11K PSA Compliance Manager Questionnaire 39 - PSA Compliance Manager Questionnaire (Form M-11K).docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Program Staff Questionnaires (Form M-11A-K) - Respondents	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	Form M-11A	Program Director Questionnaire	29 - Program Director Questionnaire (Form M-11A).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11B	LTFC Program Director Questionnaire	30 - LTFC Program Director Questionnaire (Form M-11B).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11C	Clinician Questionnaire	31 - Clinician Questionnaire (Form M-11C).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11D	LTFC Clinician Questionnaire	32 - LTFC Clinician Questionnaire (Form M-11D).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11E	Case Manager Questionnaire	33 - Case Manager Questionnaire (Form M-11E).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11F	LTFC Case Manager Questionnaire	34 - LTFC Case Manager Questionnaire (Form M-11F).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11G	Education Staff Questionnaire	35 - Education Staff Questionnaire (Form M-11G).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11H	LTFC Educational Staff Questionnaire	36 - LTFC Educational Staff Questionnaire (Form M-11H).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11I	Medical Coordinator Questionnaire	37 - Medical Coordinator Questionnaire (Form M-11I).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11J	Youth Care Worker Questionnaire	38 - Youth Care Worker Questionnaire (Form M-11J).docx	Yes	Yes	Fillable Fileable
Form and Instruction	Form M-11K	PSA Compliance Manager Questionnaire	39 - PSA Compliance Manager Questionnaire (Form M-11K).docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 756	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	756	756
Annual IC Time Burden (Hours)	756	756
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.