Form M-12C Form M-12C LTFC Client Questionnaire

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

(Revised: 09/10/20)

LTFC Client 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 child friendly terms and answer any questions the UAC 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 UAC 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 UAC monitor should ask individualized interview questions based upon the UAC 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

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

Introduction	Notes
What is your name? Tell me about what you do on a typical day. (Explore schedule, meals/nutrition, recreation, activities) 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. You probably signed many documents during the first couple of days. What do you remember about the information provided? What do you remember about: Phones? Sexual Abuse/Sexual Harassment? Mail/Visits? Grievance Procedures? Clothes? Did staff and your foster parents help you feel comfortable and explain things?
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 go to school every day, Monday to Friday, throughout the year, including the summer? If not, tell me about your schedule during the summer/long breaks. What subjects are you studying? How soon after arriving did you start school? Do you feel like you need any additional support at school?
Skills Training	Notes
Have you learned about independent living skills, like cooking, available health care, money management, and transportation? Do you attend group meetings where you learn about these topics? Tell me about what you have learned and who taught you. Are there any other independent living skills you would like to learn?
Recreation/Structured Leisure Activities	Notes
Tell me about the activities you do outside of school. What kinds of activities do you do? Where do you go? Do you go on outings to parks, museums, or other places in the community? How often? With whom? How often do you go outside for exercise? If the weather is bad, do you do exercise indoors? Do you have quiet/leisure time in which you can choose to read a book, play board games with other kids, do art, play cards, etc.? Are there any other community resources you would like to have access to?
Religious Services	Notes
Are you given a choice about participating in religious services? (Are you pressured to attend religious services?) Are you happy with the options for religious services that were provided to you?
Food	Notes
How is the food here? What kinds of things do you like to eat here? Do you receive enough food? Tell me about the snacks.
Medical	Notes
If you’re not feeling well, who do you talk to? How do they 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 to you? Do you know why you are taking the medication? Do you remember when you first visited the doctor? Why did you go? Who took you? What is the process to request medical care? Depending on time in care: Have you visited the dentist? If UAC is receiving medications: Have you always received the right medication at the right time?
Legal	Notes
When you arrived at the program, did you attend 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 ever been denied access to legal assistance while at the program? If so, please explain. What can you do if you believe you have been denied your rights or access to the required legal services?
Communication with Family	Notes
Are you able to contact your family? How often? Do you have a potential sponsor in the US? If so, are you able to contact them? How do you keep in contact with them? Where do phone calls occur? How often? How long? Do you feel that the staff or your foster parents are listening to your calls? Do you know if you can send or receive mail or e-mails? If so, how often? Do you know if you can have visitors? If yes, where do you meet? Are your foster parents or staff present during these meetings?
Meetings with CM Staff	Notes
Tell me about your meetings with your case manager. (Explore whether UAC understands the role of the case manager, how often they meet, where they meet, what they do during meetings)
Clinical Services	Notes
Tell me about the sessions with your clinician. (Explore whether UAC understands the role of the clinician, how often they meet, if they’re 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?
Program Rules	Notes
What happens when you break a rule or get in trouble? What about when other children here break a rule? Do you think the consequences for breaking rules are fair? Have you ever been hurt physically by a staff member or your foster family? Do staff or your foster parents ever act angry or mad?
Reporting a Complaint or Abuse	Notes
If you have a complaint about the program, staff, or your foster family, who do you talk to? Is there any particular person you feel comfortable talking to? Is there a form where you can a write down a complaint? Where are these forms located? Have you ever made a complaint/grievance? If so, how did the program and staff respond? If you need to report that something happened, such as abuse, how would you do it? Do you have access to a phone and know how to use it report abuse? If yes, explain where the phones are and how to use them. Do you have to ask permission to use the phone?
Safety	Notes
Have you always felt safe at the program, in your foster home, and in your community? If no, describe why you do not feel safe. 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 UACs? Are there any staff members who make you feel uncomfortable? Tell me about what you like about your foster family. Tell me about what you don’t like. Does anyone in your foster home make you feel uncomfortable? Is there anyone other than your foster family who visits the home frequently? If so, tell me about this person. Have you ever been treated badly or with disrespect? (Yelled at? Cursed at? Made fun of by staff or your foster family? Bullied by other UAC in front of staff or your foster family?) Have you ever witnessed another child being treated badly or bullied while here?
Conclusion	Notes
Re-explain that we will not say ‘who said what’ and will only share summary recommendations with program and ORR. 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 UAC 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.