Form M-13C-UF Form M-13C-UF Legal Service Provider Questionnaire

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OMB 0970-0564 [valid through 10/31/2024]

(Revised: 3/16/2022)

Stakeholder Questionnaire – Legal Service Provider – Unlicensed Facility (UF) Quarterly Health and Safety Visit

Interview Details

Program name:
Level of Care:
Stakeholder’s Name:
Date/Time of Interview:
Type of Interview (phone and/or face-to-face):
Interview Completed by:

Note: Before beginning the interview and/or providing this questionnaire to stakeholders, provide a brief introduction, including monitor role and purpose of monitoring visit, overview/purpose of interview, and clarify any questions. See Introduction Prompt for Stakeholders 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.

Notes

Are you provided with everything you need to be able to conduct provide legal services? Are you provided with adequate space to provide legal services? Are there any programmatic barriers that prevent you from being able to provide legal services?
How are you informed of new arrivals/discharges? Are you informed in a timely manner?
How is the communication with program staff?
Are you made aware of incidents that may impact a UC’s legal case (ex. Age outs, runaways, SIRs, etc.)?
Do you have issues/concerns to share with us?

Additional Notes

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 legal service providers during unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 0.75 hours per response for the legal service provider and 0.75 hours 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 UCPolicy@acf.hhs.gov.