Form M-3A Form M-3A FFS Compliance and Safety Site Visit Report

						OMB 0970-0564 [valid through MM/DD/YYYY]
						Administration for Children & Families
						Office of Refugee Resettlement
Program Name:			Date:
Level of Care:			Date of last site visit:
FFS Name:
Site Visit walk through: This is a walk through to identify and ensure compliance for major requirements and safety concerns.
"Yes" indicates compliance. "No" indicates out of compliance and requires a comment indicating specifically what was non-compliant.	Yes or No	Comments
All required bulletin board postings to educate youth about sexual abuse, sexual harassment, and reporting are posted in ALL required areas in language UC understands
Required Preprogrammed phone is accessible to UC, private, and correctly pre-programmed for UC to report sexual abuse, sexual harassment, and sexually inappropriate behavior (all three must be compliant to indicate “yes")
Grievance procedure, forms and box are in areas that UC can access and make free of fear of retaliation from staff. Instructions are clear and in language UAC understands
Clients rights are posted in language UC understands
Daily schedule is posted in language UC understands
Garza is posted
Overall appearance of the program is neat, organized, and clean that does not present any health or safety concerns
The Program is compliant with ORR's Youth Care staff to child ratio requirements
The Program is compliant with ORR's Case Manager's staff to child ratio requirements
The Program is compliant with ORR's Clinician's staff to child ratio requirements
Staff supervising the UC appear engaged and attentive to the UC/environment/role
Did the program have a Facility Inspection Checklist for a Child Friendly Environment completed?		(please note the date it was completed)
Did the Checklist for a Child Friendly Environment meet all satisfactory markings? (was it all marked "yes")		(please note any deficiencies)
Checklist: Does the program have working video cameras and are they reviewed by the program?
Checklist: Are all entry and exit alarms tested to ensure they work (includes windows and doors)?
Checklist: Do all entries and exits have safety measures? (perimeter barriers, perimeter lighting, alarms to note for entry/exit without permission)?
Observations: (recent improvements, recent repairs, shade for kids outside, old/new furniture, etc.)
Concerns: (focus on safety issues for UC or staff - blind spot supervision, etc.)
Child interviews: Child interviews are for the purposes of general information and general well-being and safety. Children have a right to refuse an interview. If this occurs, please document the reason the child refused an interview. This is not an investigation. This should not evolve into counseling. FFS and CFS are mandated reporters to CPS and law enforcement. Do not promise children anything. Do not discuss the child’s legal case. Redirect issues that move away from the intent of this site visit report and encourage them to speak with their clinician/case manager or attorney/legal services provider. If you have any immediate safety concerns, please contact the FFS Supervisor.
Interview three minors: a new placement, a UC with an average LOS, and a UC with a longer LOS. Mark the box next to the child's age range for each child interviewed.	Child 1 – New Placement		Child 2 – Average LOS		Child 3- Long LOS
		0-6 year old		0-6 year old		0-6 year old
		7-12 year old		7-12 year old		7-12 year old
		13-17 year old		13-17 year old		13-18 year old
	Yes or No	Comments	Yes or No	Comments	Yes or No	Comments
Interpreter used by FFS or CFS (if yes, note language)
Does the UC have the opportunity for daily Recreation (large and small muscle)?
Does the UC have access or a choice to participate in preferred Religious Services?
Does the UC have Leisure Time?
Does the UC meet with his/her CM once per week?
Does the UC meet with his/her Clinician for one hour sessions per week?
Does the UC have a Clinical Group?
Are there Community Meetings the UC can particpate in?
Does the UC get at least two calls per week with his/her parent and/or sponsor?
Are Sexual Abuse Hotline pre-programmed phones accessible to the UC at any time?
Does the UC understand his/her rights?
Is the UC aware of the legal services provider and his/her access to the LSP?
Does the UC understand his/her family reunification case?
Does the UC attend school/education classes for at least 6 hours per day Monday-Friday?
Is the UC aware how to file a grievance? If the UC ever filed a grievance note this and how it was addressed in the comment box.
Do you feel safe?
Do you like living at this shelter? If yes, what is that you like about the shelter? If no, what is it that you don't like and what would you like to see changed?
The last three questions are open ended and not a YES or NO answer. Please tailor the questions to ensure the UAC understands the question
Is there anything your case manager or staff here could do that would help you feel more comfortable going to live with your sponsor?
Who would you ask for help if you have a problem while living here at the program?
Do you have anything else I have not asked you about that you want to tell me?
Please mark YES or NO for anything the FFS or CFS want to follow up on and any observations about the interviews should be noted in the comments.
Trends/Comments: Please provide a narrative discussion of your main findings and areas of potential concern. Did you identify any potential issues to monitor or for additional follow up? List any specific issues that need to be reviewed again during the next site visit?
Follow up/Action Items: Follow up on any Corrective Actions, SA/SIRs, Emergency SIRs, Notice of Concern from PRS provider, any outcomes or issues from a previous site visit by the FFS, CFS, or Monitoring Team?
Follow up/Action Items				Responsible Party	Due Date
THE PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to allow ORR Federal Field Specialists to document site visit observations and interview responses. Public reporting burden for this collection of information is estimated to average 1.0 hour per response, 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.