Form M-10A-UF Unlicensed Facility Personnel File Checklist

					OMB 0970-0564 [valid through MM/DD/2026]
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 ensure that programs are meeting ORR policies and procedures related to the maintenance of personnel files during quarterly site visits. 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.
Updated: 04/22/2020
Unlicensed Facility Personnel File Checklist
Facility
Name
Date of Hire
Reviewer
Date of Review
Current Position (Past Positions?)
General Documentation:	In file Y/N	Date, if applicable	Notes
Resume (Effective: 04/15/17)
Job Description (Effective: 04/15/17)
Employment Application (to include asking about past work and volunteer experiences) (Effective: 04/15/17)
Personal References (at least one) (Effective: 01/14/19)
Professional References (Effective: 04/15/17)
Educational records/diploma (Effective: 04/15/17)
Professional licensure, if applicable (Effective: 04/15/17)
Meet minimum educational and work experience requirements?
Criteria for the employee's selction, hiring, suspension, or termination (Effective: 04/15/17)
I-9 Employment Eligibility Documents (I-9 form and copies of required I.D documents.) (Effective: 04/15/17)
Results of medical exam (as required by State licensing, including results of TB tests) (Effective: 04/15/17)
Child Abuse Mandated Reporter Agreement (signed.) (Effective: 04/15/17)
Confidentiality Policy Acknowledgement (Effective: 04/15/17)
Annual Performance Review (annual, signed, with employee's written comments, must incl. questions about any prior misconduct since last background investigation) (Effective: 02/22/15)
Code of Conduct (signed by applicant (staff hired since Feb. 2019), acknowledging receipt). (Effective: 01/14/19, as applicable per care provider's Cooperative Agreements). (Care provider facilities must also share a copy of the code of conduct in Section 4.3.5 with each applicant. Care provider facilities must keep a copy of these documents in the applicant’s personnel file.)
Prevent and Report Sexual Abuse and Harassment (signed by applicant (staff hired since Feb. 2019), acknowledging receipt) (Effective: 01/14/19)
Fraud Scheme Acknowledgement (signed; Fraud Scheme training document signed by employee is acceptable)
Background Investigation Documentation:	In file Y/N	Initial Clearance Date	Notes	Updated Clearance Date	Notes
FBI fingerprint check of national and state criminal history repositories (Documentation of the review and conclusion. Completed prior to employment start date)
CPS check (child abuse and neglect record check) with the staff's State(s) of U.S. residence for the last 5 years (Documentation of the review and conclusion. Completed prior to employment start date)
Background Investigation updates at a minimum of every 5 years of the staff/contractor/volunteer's start date or last background investigation update. (Documentation of the review and conclusion)
Driver's Record and Clearance (if transporting children and youth.) (Effective: 04/15/17)
Efforts to ask applicants about previous misconduct and employee's response (Effective: 02/22/15)
Efforts to contact past employers where applicant had access to children and youth, including asking about any substantiated allegations of sexual abuse and sexual harassment (Effective: 02/22/15)
Pre-Service Trainings (Before the employee has access to UAC)	In file Y/N	Date	Notes (i.e. #hours obtained, topic title if different from ORR, etc.)
ORR Standards to Prevent, Detect, and Respond to SA and SH involving UAC. New employees must complete training before hire. (per training list under 4.3.6) (Effective: 02/22/15)
How to detect and assess signs of SA and SH (Medical and MH staff ONLY)
How to preserve physical evidence of SA (Medical and MH staff ONLY)
How to respond effectively and professionally to juvenile victims of SA and SH (Medical and MH staff ONLY)
Forensic Examinations (Medical staff that conduct forensic exams ONLY)
State license required trainings (Foster Parents - 30 hours of MAPP training or equivalent foster parent training curriculum.) (Effective: 04/15/17)
Pre-Service trainings include date, number of hours, subject-matter, a confirmation that the employee understood each training, and the name of the individual and/or entity providing the training (spot check)
Annual Trainings	In file? Y/N	Current Date	Notes (i.e. #hours obtained, topic title if different from ORR, etc.)	Previous FYs Date	Notes (i.e. #hours obtained, topic title if different from ORR, etc.)
40 hours per year (Effective: 04/15/17)
Flores Settlement Agreement, HSA 2002, TVPRA 2008, and Perez-Olano (2 hours per year) (Effective: 04/15/17)
ORR Policies and Procedures (10 hours per year) (Effective: 04/15/17)
ORR-provided refresher training about avoiding inappropriate relationships and reporting sexual abuse and sexual harassment (every six months) (Effective: 01/14/19)
ORR Standards to Prevent, Detect, and Respond to SA and SH involving UAC (per training list under 4.3.6)
How to detect and assess signs of SA and SH (Medical and MH staff ONLY)
How to preserve physical evidence of SA (Medical and MH staff ONLY)
How to respond effectively and professionally to juvenile victims of SA and SH (Medical and MH staff ONLY)
Forensic Examinations (Medical staff that conduct forensic exams ONLY)
State licensing requirements (Foster Parents) (Effective: 04/15/17)
Annual trainings include date, number of hours, and topic area, a confirmation that the employee understood each training, and the name of the individual and/or entity providing the training (spot check. Effective: 04/15/17)
Trainings Every Two Years Per Cooperative Agreement	In file? Y/N	Current Date	Notes (i.e. hours obtained, topic title if different from ORR, etc.)	Previous FYs Date	Notes (i.e. hours obtained, topic title if different from ORR, etc.)
Safe and Timely Release Process (Effective: 04/15/17)
Cultural Competency, including awareness of and sensitivity to different cultural backgrounds (Effective: 04/15/17)
Prohibition against providing legal advice or counsel (Effective: 04/15/17)
Strengths-based behavior management approaches and trauma-informed care approaches, such as using conflict resolution, problem solving skills, using rewards and consequences, de-escalation techniques and helping children and youth learn accoutnability and self-control (Effective: 04/15/17)
Prohibition against conflicts of interest (Effective: 04/15/17)
Crisis/intervention procedures and techniques (Effective: 04/15/17)
Immigration and child welfare systems (local, national, international) (Effective: 04/15/17)
Child development theory (Effective: 04/15/17)
Issues related to loss and family separation (Effective: 04/15/17)
Common health and mental health issues (Effective: 04/15/17)
First aid and CPR (Effective: 04/15/17)
Medication management (Staff and foster parents who dispense medications must also receive medication administration training)
Infection control procedures and OSHA or equivalent course that covers blood bourne pathogens, airborne pathogens, and employee safety (Effective: 04/15/17)
Working with victims of human trafficking and other crimes (Effective: 04/15/17)
Mandatory child abuse and neglect reporting requirements: prevention, signs, and reporting (Effective: 04/15/17)
Professional boundaries (Effective: 04/15/17)
Emergency disaster preparedness (Effective: 04/15/17)
Code of Conduct and Conflicts of Interest (Effective: 04/15/17)
Grievance policies and procedures (Effective: 04/15/17)
Incident Reporting (Effective: 04/15/17)
Child-friendly and trauma informed interviewing, assessment, observation, and identification of suspected victims of human trafficking and children who have been smuggled into the country (Staff and foster Parents)
Trainings include date, number of hours, and topic area, a confirmation that the employee understood each training; and the name of the individual and/or entity providing the training (spot check; Effective: 04/15/17)
COMMENTS