Form M-9A-UF Form M-9A-UF Unlicensed Facility On-Site Monitoring Checklist

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

M-9A-UF On Site Monitoring Checklist

Unlicensed Facility OnSite Monitoring Checklist (Form M-9A-UF) - Recordkeeping

OMB: 0970-0564

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OMB 0970-0564 [valid through MM/DD/2026]


Unlicensed Facility Quarterly Health and Safety Monitoring Checklist – Facility Walkthrough



Compliant?


Compliant?

  1. General Safety and Security

Y

N

n/a


Y

N

n/a

Controlled entry/exit of premises




Knives/sharp objects inaccessible to UC




Prohibited from allowing entry of any individual (except UC in the process of admission) who meet any COVID-19 criteria




Cleaning chemicals maintained in a locked area




Alarms system for all areas of the residential structure




Medical supplies/prescriptions inaccessible to UC




Video monitoring in common and living areas and classrooms




Other unsafe areas inaccessible to UC




Video monitoring for exterior of building & surrounding premises




Vehicle(s) inspection stickers up-to-date




Ability to download video footage permanently




Vehicle(s) appear to be in good repair (including fire extinguisher and first aid kit)




System for tracking and regulating UC movement




Vehicle (s) contain working seat belts




Meeting UC to floor staff ratios/appropriate supervision




Evacuation procedures posted prominently on each floor and at eye level for children and youth




Mirrored windows”/window in offices where staff meet with child 1:1




Fire extinguishers and smoke detectors in good working order and inspected (as required)




Infants/Toddlers – age appropriate furniture (e.g. cribs/bedding, high chairs, toys, outlet covers)




Play equipment safe and in good repair








Compliant?


Compliant?

  1. Confidentiality

Y

N

n/a


Y

N

n/a

Case files in secure location (open and closed)




Case files safe from physical damage




Only individuals with a need to know basis have access to the case files




Pre-programmed telephones (Required: UC SA Hotline, CPS, Local Community Service Provider; Highly recommended: Top 3 consulates and LSP)




Private place for UC to make phone calls (including pre-programmed phones)

























Compliant?


Compliant?

  1. General Residential Structure - Indoors

Y

N

n/a


Y

N

n/a

Clean




Kitchen




Child-friendly (e.g. no safety/trip hazards)




UC dietary restrictions posted/accessible




Furniture and building are properly maintained




Food stored in a sanitary manner




Well-ventilated




Bathrooms




Adequately heated/cooled




Soap




Identified UC Medical Quarantine/Isolation Space




Toilet paper




Bedrooms




Working toilets




Natural light/Dark at night




Hot/cold water




Provision of appropriate linens




Separated by gender




Adequately accommodate all UC (per State Licensing)




Appropriate privacy




Separated by gender (per licensing)




Hygiene/grooming items




Adequately accommodate all youth (e.g. individual bed with mattress for each youth)




Towels




Provision of appropriate bed linens















Compliant?


Compliant?

  1. Documents that should be posted/accessible to youth (Spanish, English, and any other language as needed)

Y

N

n/a


Y

N

n/a

Posters with phone numbers for UC to report sexual abuse/harassment




Care Provider AND ORR Pamphlets on sexual abuse/harassment




Notice to Pregnant Females (Garza vs. Azar) next to posters




Extra copies of UC grievance forms




Grievance Procedures (in common areas)




Program Rules




Saravia Notice (English and Spanish posted next to Garza and Sexual Abuse/Harassment notices) – posting currently applicable to Secure, Staff Secure and RTC – effective 10/22/2020













Compliant?


Compliant?

  1. Other

Y

N

n/a


Y

N

n/a

UC/Staff provided/wearing face masks and/or offered face masks, as applicable




Emergency Evacuations Notification List (must be posted in office area and includes: ORR contacts, DHS contact, and local law enforcement)




Car Seats (if transporting young children)




No Touch Thermometers available




Sufficient supply of Face Mask / Hand Sanitizers / Gloves









Walkthrough NOTES


  1. General Safety and Security



  1. Confidentiality




  1. General Residential Structure



  1. Documents that should be posted





  1. Other





On-Site Monitoring Checklist - Other



Observed?


Observed?

Services to Potentially Observe

Y

N

n/a


Y

N

n/a

Education




Group counseling/community meeting




Recreation – large muscle, outdoors




Meals





Reviewed?


Reviewed?

Logs/Schedules to Potentially Review

Y

N

n/a


Y

N

n/a

Fire Drills Logs




Grievance binder




Daily (Shift) logs




Group Counseling Curriculum




System for inspecting vehicles




Visitor Logs




Prescription/Non-prescription medication logs




Care Provider Policies for UC to Request Emergency and Non-Emergency Health Care Services




Spot Inspections and Quarterly Safety Assessments




UC Temperature Tracker




Facility inspection checklist (safety check)

















Other NOTES

Services to Observe












Logs to Review














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 document their findings during the walkthrough portion of unlicensed facility quarterly site visits. Public reporting burden for this collection of information is estimated to average 4 hours 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 UACPolicy@acf.hhs.gov.

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