Form M-12D Form M-12D Secure Client Questionnaire

OMB 0970-0564 [valid through MM/DD/2024]

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(Revised: 12/16/20)

SECURE UC Questionnaire

Instructions: The interviewer should explain to the minor that the interview is not mandatory and confirm that he/she is voluntarily participating in the interview without their attorney(s) present. The interviewer should also explain to the minor the monitor’s role, the purpose of the interview, and the use/role of an interpreter (if applicable). Explain the purpose of your visit in youth friendly terms and answer any questions the UC has about ORR or your visit. Also, reassure minor to not be nervous if he/she is nervous about the interview. Please see the "Introduction Prompt for UC Questionnaire" for additional guidance.

Questions in bold should be asked during the interview if possible. Other questions are optional prompts to assist the interviewer. These questions are NOT intended to be asked verbatim. Ask questions that help establish rapport. The UC monitor should ask individualized interview questions based upon the UC case file review and the circumstances of the inspection.

Name of witness present confirming minor volunteered to be interviewed without their attorney(s) present:_______________________________

Interview Details

UC Name:	A#:
Date of Admission:	Gender/Age:
Date/Time of Interview:	Country of Origin:
Name of Evaluator:	Name of Interpreter:
Primary Language of UC:	Language of Interview:
Appropriately dressed? Yes No	Appropriately groomed? Yes No

Introduction	Notes
What is your name? May I call you by your first name or would you prefer Mr. …. Tell me about what you do on a typical day here. (Explore schedule, meals, recreation, activities) And detail your typical day on weekends? What are the things you like about the program? What are the things you don’t like about the program?
Admission/Orientation	Notes
Tell me about what happened when you first arrived at the program. Would you explain why you are in a secure facility? Did staff provide you the reasons (verbally? In writing? ) why you are in this secure level of care? Do you have any questions about the reasons you are here? Describe how you are being treated since you arrived. Did you receive a copy of the form that provided reasons for your placement in secure level of care? Based on how long you have been here, has this been re-explained to you monthly? You probably signed many documents during the first couple of days here. What do you remember about the information provided? Phones? Sexual Abuse/Sexual Harassment? Mail/Visits? Grievance Procedures? Reasons in secure facility? Clothes? Uniforms? Toilet articles? (How does that work at this facility?)
Education/School	Notes
Tell me about your experience in school here. What is a normal school day like? How are your classes? Do you enjoy going to school? Do you feel like your teachers really care about your education? Do you feel safe when in school? If there is any doubt they are receiving all of the required subjects (Science, Social Studies, Math, Reading, Writing, Physical Education, and English as a Second Language): Are you taking a class on ___________? What are you learning in that class? If there is any doubt they are receiving the required hours of instruction: Do you have class every day, Monday to Friday? How long do you spend in school each day?
Recreation/Structured Leisure Activities	Notes
Tell me about the activities you do at this facility? What kinds of activities do you do? During the day? In the evening after school? On weekends? How often do you go in the outside exercise area? On weekends? What do you do when the weather does not allow you to have recreation/physical activities outdoors? Do you have quiet/leisure time in which you can choose other activities? What can you do here: play board games with other kids, do art, play cards, read books, watch movies/TV? Any other leisure activities?
Religious Services	Notes
What kinds of religious services are offered here? Do religious service providers visit the program or are all services virtual (TV; video)?
Food/Snacks	Notes
How is the food here? Are there any foods you like to eat here? Do you receive enough food? Please share any concerns or suggestions regarding the food? Tell me about the snacks.
Medical	Notes
If you’re not feeling well, who do you talk to? How do staff respond? Quickly enough? Do you have any health concerns? Have they been addressed? Do you currently take any medication? If so, who provides the medication for you? Do you know why you are taking the medication? What is the process to request medical care? Depending on time in care: Have you visited the dentist? If UC is receiving medications: Have you always received the right medication at the right time? Do you feel like the medical staff care about you and treat you with respect?
Legal	Notes
When you arrived at the program, did you receive a “Know Your Rights” presentation? Did you receive a Legal Resource Guide, which has a list of free attorneys for the state you are in? Do you know that you have a right to talk to an attorney? Have you had access to legal assistance while at the program? If you wanted to talk to legal services, how would you go about doing that?
Communication with Family	Notes
Are you able to contact your family/sponsor? How often are you able to contact your family/sponsor? Where do phone calls occur? How often? How long? Are you able to have a conversation with your family with privacy? How do you keep in contact with them? Do you know if you can send or receive mail? If you wanted to send mail to your family, how would you do that?
Meetings with CM Staff/Reunification/Discharge Planning	Notes
Tell me about your meetings with your case manager. (Explore whether UC understands the role of the case manager, how often they meet, what they do during meetings) Would you share your understanding of your current case and plans for the future?
Clinical Services	Notes
Tell me about the sessions with your clinician. (Explore whether UC understands the role of the clinician, how often they meet, if comfortable during 1:1 meeting, what they do during sessions) Do those sessions help you? If so, how? If not, how could the sessions be improved? Do you feel that your sessions with clinician (individual or group) help you adjust to the program here and plan for the future?
Program Rules and Behavior Management	Notes
Have you ever been treated disrespectfully by a staff member? Or physically abused during a restraint incident? Are there any staff here that don’t treat you with dignity and respect? Explain. Please explain the ‘lock down’ procedures if there is a serious incident (e.g. a fight between two youth)? Please explain a typical day in terms of how long you are in your room? On weekends and evenings? Do you feel that staff try to limit the amount of time a youth is in room because of disruptive incident? Have you ever been restrained? If so, why? How were you restrained? How does the ‘behavior system’ work here? How do you move between levels? What happens when you break a rule or get in trouble? What about when other youth here break a rule? Do you think the consequences for breaking rules are fair? Have you observed any fights between youth when staff were not present? Are there any serious issues with peers bullying or teasing? If yes, do staff members know and what have they done to address the issue?
Reporting a Complaint or Abuse	Notes
If you have a complaint about the program or about staff, who would you talk to? Are there any particular staff you would feel comfortable talking to? Is there a form where you can write down a complaint? Where are these forms located? Have you ever submitted a formal complaint/grievance? If so, how did the program and staff respond? If you need to report that something happened, such as physical or verbal abuse, how would you do it? Do you know how to use the phone to report abuse? If yes, where are the phones and how are they used? Do you have to ask permission to use the phone?
Safety	Notes
Do you feel safe here? If no, describe when you did not feel safe at the program. If the child discloses feeling unsafe, the evaluator must elevate the issue for appropriate action, including connection with clinician when necessary. Tell me what you like most about the staff here. Tell me what you don’t like about the staff. Are there any staff members who you avoid or who should not be working with UCs? Are there any staff members who make you feel uncomfortable? Which staff member has been most helpful and responsive to your needs? Have you ever been treated badly or with disrespect? (Yelled at? Cursed at? Made fun of by staff? Bullied by other UC in front of staff?) Have you ever witnessed another child being treated badly or bullied while here?
Conclusion	Notes
Unless we have discussed an exception, re-explain that we will not say ‘who said what’ and will share summary observations/recommendations with program and ORR. Exceptions: UC request for specific service (e.g. replacement of worn-out tennis shoes) that requires case specific follow-up; safety issue that needs to be reported.) Is there anything else you want to tell me? Or should tell me? Maybe something I haven’t asked you? Suggestions to improve the program?
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 Monitoring Team staff to interview and document responses from UC during biennial site visits. Public reporting burden for this collection of information is estimated to average 0.5 hour per response (plus an additional 0.5 hour if the site visit is performed by a 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 UCPolicy@acf.hhs.gov.