Form M-17A Preaudit Questionnaire and Audit Documentation Requested

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

OFFICE OF REFUGEE RESETTLEMENT
PREVENTION OF SEXUAL ABUSE
COMPLIANCE AUDIT TOOL
ICF PREAUDIT QUESTIONNAIRE
AND
REQUESTED DOCUMENTATION
CHECKLIST

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 auditors to collect
information and supporting documents related to the overall functioning and oversight of the care provider program as part of the preaudit process for. Audits are required in the Interim
Final Rule on Standards to Prevent, Detect, and Respond to Sexual Abuse and Sexual Harassment Involving Unaccompanied Children (45 CFR Part L). Public reporting burden for this
collection of information is estimated to average 4 hours per response for the care provider and 3 hours per response for the contractor performing the audit, 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.

PREAUDIT QUESTIONNAIRE
Preaudit Questionnaire Information
Completed by:
Date completed:
Date revised (if relevant):
Care Provider Information
Name of Care Provider:

Governing Authority or Parent Facility (if applicable):

Physical Address:

City, State, Zip:

Mailing Address:

City, State, Zip:

The Facility is:

 Therapeutic
Group Home

Telephone:

 Transitional
Foster Care

 Residential
 Staff Secure
Treatment Center
 Therapeutic
 Shelter
Staff Secure
State Licensing Contact
Email:
Information (if applicable):

Phone:

Care Provider Program Director
Name:
Email:

Preaudit Questionnaire and Requested Documentation Checklist

Telephone:

ICF | 2

Preaudit Questionnaire Information
PSA Compliance Manager
Name:

Title:

Email:

Telephone:

PSA Compliance Manager reports to:
Date of the last facility
PSA audit (if applicable):
Care Provider Characteristics
Licensed facility capacity:
Age and gender facility is licensed to house:
If exceptions to licensing capacity and/or age or gender served has been sought, please describe and provide relevant licensing documentation:

Current population of facility:
Number of unaccompanied children admitted to care provider during
the past 12 months:
Number of unaccompanied children admitted to care provider during
the past 12 months whose length of stay was 45 days or more:
Average daily population for the past 12 months:
Age range of population:

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 3

Preaudit Questionnaire Information
Average length of stay:
Number of staff currently employed by the facility who may have
contact with unaccompanied children:
Number of staff hired during the past 12 months who may have contact
with unaccompanied children:
Number of contractors in the past 12 months for services who may
have contact with unaccompanied children:
Number of volunteers in the past 12 months who may have contact
with unaccompanied children:
Physical Plant
Number of buildings:
Number of housing units (where children sleep):
Has the facility installed or updated a video monitoring system,
electronic surveillance system, or other monitoring technology in the
past 12 months? Or since the date of the last audit?

Preaudit Questionnaire and Requested Documentation Checklist

 Yes
 No
If yes, please describe and provide date of installation or update:

ICF | 4

Preaudit Questionnaire Information
Please provide a description of the facility
video monitoring system, electronic
surveillance system, or other monitoring
technology (e.g., cameras, etc.):

Medical and Mental Health and Forensic Medical Exams
Are medical services provided onsite?

 Yes
 No

If no, describe how and where services are provided and who provides
medical services:
Are mental health services provided onsite?

 Yes
 No

If no, describe how and where services are provided and who provides
mental health services:
Where are sexual assault forensic medical exams provided?
Select all that apply:

Preaudit Questionnaire and Requested Documentation Checklist






Onsite
Local hospital/clinic
Rape crisis center
Other (please name and describe):

ICF | 5

REQUESTED DOCUMENTATION CHECKLIST
Policies/Procedures/Other Documents
Background Information
Preaudit

Onsite Audit

Please provide the documents listed under the Preaudit
column when returning the questionnaire via the link
provided in the facility notice letter.
 Schematic (layout) of facility

 A list of all current and former employees who have contact with
children that includes their title, assignment, shift, and dates of
employment for the last 12 months

 Current agency organizational chart

 A list of unaccompanied children by housing area and a list of
unaccompanied children alphabetically

 If possible, access to facility personnel records

 A list of all current and former contractors and volunteers with dates
of service for the last 12 months

 If possible, access to facility training records

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 6

Policies/Procedures/Other Documents
Subpart B – Prevention Planning
§411.11–§411.17
Standard

Preaudit

§411.11 – Zero
tolerance of
sexual abuse
and sexual
harassment,
ORR’s
Prevention of
Sexual Abuse
Coordinator
(ORR’s
Preventing
Sexual Assault
Coordinator)

 Agency policy mandating zero tolerance of all forms of
sexual abuse and sexual harassment in facilities
operated directly or under contract

§411.13 –
Unaccompanied
Children (UC)
Supervision and
monitoring

 Facility’s policy and/or process for ensuring adequate
level of staffing and monitoring of UC

§411.14 – Limits
to cross-gender
viewing and
searches

 Facility policy and/or process for ensuring compliance
with standard 411.14 – limits to cross-gender viewing
and searches

Onsite Audit
 Not applicable (NA)

 Implementation plan: Facility policy outlining how the
facility will implement the agency’s zero-tolerance
approach to preventing, detecting, and responding to
sexual abuse and sexual harassment
 Employed or designated Office of Refugee
Resettlement (ORR) approved Prevention of Sexual
Abuse (PSA) Compliance Manager with sufficient time
and authority to develop, implement, and oversee the
care provider facility’s efforts to comply with this
provision and serve as a point of contact for ORR’s
PSA Coordinator

 Sample of records or documentation of unannounced
rounds conducted in the last 12 months

 If facility prohibits pat-down searches, policy stating as
such

 Placement of video monitoring cameras
 Records of unannounced rounds (day and night shifts) to
identify and deter sexual abuse and sexual harassment
conducted in the last 12 months
 Staff training records of youth care workers for past 12
months
 Documentation and Sexual Abuse Significant Incident
Reports (SA/SIRs) of pat-down searches in the past 12
months

 Documentation of instances where same gender staff
assisted viewing children under age 6 needing
assistance; a UC with special needs or a UC
requesting or requiring assistance when such viewing
is incidental to routine room checks, in connection with
medical examination, or in connection to a monitored
bowel movement

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 7

Policies/Procedures/Other Documents
Subpart B – Prevention Planning
§411.11–§411.17
Standard

Preaudit

Onsite Audit

 Documentation of exigent circumstances requiring
deviance from 411.14 and reporting documentation to
ORR
 Facility training curriculum and process for training
youth care worker staff specific to pat-down searches
and searches of cross-gender, transgender, and
intersex UCs
§411.15 –
Accommodating
UCs with
disabilities and
UCs who are
limited English
proficient (LEP)

 Facility steps/processes to accommodate UCs with
disabilities to participate in or benefit from all aspects
of the agency’s efforts to prevent, detect, and respond
to sexual abuse and sexual harassment

 Documentation of circumstances in which UC interpreters,
readers, and other UC assistants were used

 Facility steps/processes to accommodate UCs with
limited English proficiency to participate in or benefit
from all aspects of the agency’s efforts to prevent,
detect, and respond to sexual abuse and sexual
harassment
 If applicable, written materials used for effective
communication about the prevention of sexual abuse,
sexual harassment, and other inappropriate sexual
behavior with UCs with disabilities, intellectual
disabilities, limited reading skills, or who are blind or
have low vision

§411.16 – Hiring
and promotion
decisions

 Facility policies/decision making on hiring of
employees and contractors and promotion of
employees, including policies governing criminal
background checks as required per ORR Policy 4.3.3
 In the past 12 months, the number of persons hired
who may have contact with UCs who have had
criminal background checks

Preaudit Questionnaire and Requested Documentation Checklist

PLEASE NOTE: If able to access records during Preaudit
Phase, this will be considered a part of the Preaudit Phase
work. If records are not accessible during Preaudit Phase,
reviews will be completed during the Onsite Phase.
 Files of persons hired or promoted in the last 12 months to
determine whether proper criminal-record background checks
have been conducted, questions regarding past conduct
were asked and answered, and efforts to contact all prior
institutional employers of an applicant to obtain information

ICF | 8

Policies/Procedures/Other Documents
Subpart B – Prevention Planning
§411.11–§411.17
Standard

Preaudit

Onsite Audit

 In the past 12 months, the number of new contracts
for services involving people who may have contact
with UCs who have had criminal background checks

on substantiated allegations of sexual abuse or sexual
harassment or any resignation during a pending investigation
of alleged sexual abuse or sexual harassment

 In the past 12 months, the number of new volunteers
who may have contact with UCs who have had
criminal background checks

 Files of personnel hired in the past 12 months to determine
that the agency has completed checks consistent with 411.16
 Records of background checks of contractors hired in the
past 12 months who might have contact with UCs
 Records of background checks of new volunteers hired in the
past 12 months who might have contact with UCs

 Documentation of background record checks of current
employees at five-year intervals when applicable

 Copies of performance evaluations of staff within the last 12
months
§411.17 –
Upgrades to
facilities and
technology

 NA

Preaudit Questionnaire and Requested Documentation Checklist

 Documentation of the facility’s consideration/planning in
design, acquisition, expansion, or modification of new or
existing facility
 Minutes from meetings and/or other documentation
referencing the installation or update of monitoring
technology

ICF | 9

Policies/Procedures/Other Documents
Subpart C – Responsive Planning
§411.21–§411.22
Standard
§411.21 – Victim
advocacy,
access to
counselors, and
forensic medical
examinations

Preaudit

Onsite Audit

 Facility policy/procedures for the best use of
available crisis intervention and counseling
community resources and services

 Log indicating use of program’s licensed clinician to provide
crisis intervention and trauma services for UC if no rape crisis
available or due to UC preference

 Facility policy/procedures for the availability of rape
crisis center victim advocates and, if not available,
the facility process and procedures for use of
facility staff providing these services

 Documentation of efforts to provide forensic examinations by
SAFEs or SANEs, if applicable

 Facility policy/procedures associated with
conducting forensic medical examinations on UCs,
including the presence of the child’s outside or
internal victim advocate if requested by child

 Log or other recordkeeping of UCs having forensic medical
examinations and name of person who conducted examination
(SAFE, SANE, medical practitioner, etc.), if applicable

 When Sexual Assault Nurse Examiners (SANEs) or
Sexual Assault Forensic Examiners (SAFEs) are
not available, process/procedures addressing a
qualified medical practitioner performing forensic
medical examinations

 Documentation to corroborate that all victims of sexual abuse
have access to forensic medical examinations

 Log or other recordkeeping of UCs requesting the presence of
outside or internal victim advocate
 The number of forensic medical exams conducted during the
past 12 months, the number performed by SANE/SAFEs, and
the number performed by qualified medical practitioner

 List of community crisis intervention and counseling
resources and services available to UCs
 Documentation of agreements with rape crisis
center for services and/or documentation of efforts
§411.22 –
Policies to
ensure
investigation of
allegations and
appropriate
agency oversight

 Policies and/or process for referral of investigations
of allegations of sexual abuse or sexual
harassment and reporting of allegations to
Department of Justice and ORR, and facility
requirement to cooperate with investigations
 Policies and/or procedures governing record
retention of documentation of all reports and
referrals of allegations of sexual abuse and sexual
harassment

Preaudit Questionnaire and Requested Documentation Checklist

 Documents of reports of sexual abuse, sexual harassment,
inappropriate sexual behavior, and code of conduct violations,
and documentation of investigations including full investigative
report(s) with findings
 Documentation of referrals of allegations of sexual abuse and
sexual harassment

ICF | 10

Policies/Procedures/Other Documents
Subpart C – Responsive Planning
§411.21–§411.22
Standard

Preaudit

Onsite Audit

 Copy of written memorandum of understanding or
other agreement specific to investigations of sexual
abuse or sexual harassment with the law
enforcement agency, designated state or local child
protective services, and/or state or local licensing
agencies responsible for conducting sexual abuse
and sexual harassment investigations (If no written
memorandum of understanding or agreement,
documentation indicating attempts to secure
memorandum of understanding or agreement)

Policies/Procedures/Other Documents
Subpart D – Training and Education
§411.31 – §411.34
Standard
§411.31 – Care
provider facility
staff training

Preaudit
 Facility training policy and/or procedures
 Staff training curriculum with required elements
under §411.31 (a) 1–13, which includes:
1. ORR and the care provider facility’s zerotolerance policies for all forms of sexual abuse
and sexual harassment
2. Right of UCs and staff to be free from sexual
abuse and sexual harassment and from
retaliation for reporting abuse and harassment
3. Definitions and examples of prohibited and
illegal sexual behavior
4. Recognition of situations where sexual abuse
or sexual harassment may occur
5. Recognition of physical, behavioral, and
emotional signs of sexual abuse and methods

Preaudit Questionnaire and Requested Documentation Checklist

Onsite Audit
PLEASE NOTE: If able to access records during Preaudit
Phase, this will be considered a part of the Preaudit Phase
work. If records are not accessible during Preaudit Phase,
reviews will be completed during the Onsite Phase.
 Sample of training records for compliance with standards and
ORR policy guide 4.3.6

ICF | 11

Policies/Procedures/Other Documents
Subpart D – Training and Education
§411.31 – §411.34
Standard

Preaudit
6.
7.

8.

9.

10.

11.
12.

13.
14.

Onsite Audit

of preventing and responding to such
occurrences
How to avoid inappropriate relationships with
UCs
How to communicate effectively and
professionally with UCs, including UCs who
are lesbian, gay, bisexual, transgender,
questioning, or intersex (LGBTQI+)
Procedures for reporting knowledge or
suspicion of sexual abuse and sexual
harassment as well as how to comply with
relevant laws related to mandatory reporting
The requirement to limit reporting of sexual
abuse and sexual harassment to personnel
with a need to know in order to make
decisions concerning the victim’s welfare and
for law enforcement, investigative, or
prosecutorial purposes
Cultural sensitivity toward diverse
understandings of acceptable and
unacceptable sexual behavior and appropriate
terms and concepts to use when discussing
sex, sexual abuse, and sexual harassment
with a culturally diverse population
Sensitivity and awareness regarding past
trauma UCs may have experienced
Knowledge of all existing resources for UCs,
both inside and outside the care provider
facility, that provide treatment and counseling
for trauma and legal advocacy for victims
General cultural competency and sensitivity to
the culture and age of UCs
Proper procedures for conducting professional
pat-down searches, including cross-gender
pat-down searches and searches of

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 12

Policies/Procedures/Other Documents
Subpart D – Training and Education
§411.31 – §411.34
Standard

Preaudit

Onsite Audit

transgender and intersex UCs in a respectful
and least-intrusive manner (If facility has
elected to prohibit pat-down searches, provide
a copy of the policy stating such)
 Staff training curriculum for refresher training on
the above topics
 Staff training curriculum for 6-month refresher
training on topic of avoiding inappropriate
relationships and reporting sexual abuse and
sexual harassment
§411.32 –
Volunteer and
contractor
training

 Training curriculum for volunteers and contractors
who have contact with UCs
 Sample documentation of information provided
(e.g., handbook or information sheet)

PLEASE NOTE: If able to access records during Preaudit
Phase, this will be considered a part of the Preaudit Phase
work. If records are not accessible during Preaudit Phase,
reviews will be completed during the Onsite Phase.
 Training records for volunteers and contractors who have
contact with UCs

§411.33 – UC
education

 Facility intake process for ensuring UCs are
notified and informed of the facility’s zero-tolerance
policies and procedures
 Sample documentation of information provided to
UCs (e.g., handbook or information sheet)
 Facility policy and/or process for ensuring
notification, orientation, and instructions are in
formats accessible to UCs, are age and culturally
appropriate, and are separate in time and manner
than information provided in their immigration case

PLEASE NOTE: If able to access records during Preaudit
Phase, this will be considered a part of the Preaudit Phase
work. If records are not accessible during Preaudit Phase,
reviews will be completed during the Onsite Phase.
 Intake records of UCs entering facility in past 12 months (spot
check)
 Log or other recordkeeping corroborating that those UCs
received information required by the standard at intake (e.g., UC
signature)

 Copy of required pamphlet in accordance with
§411.15 (e)

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 13

Policies/Procedures/Other Documents
Subpart D – Training and Education
§411.31 – §411.34
Standard

Preaudit

Onsite Audit
 Education and informational materials (posters, UC handbook,
etc.) in compliance with the standard (materials in multiple
languages, if applicable)

 Logs and/or documentation of refresher training of ORR
education of UCs

§411.34 –
Specialized
training: Medical
and mental
healthcare staff

 Training curriculum for medical and mental
healthcare staff (employed and contracted)

Preaudit Questionnaire and Requested Documentation Checklist

PLEASE NOTE: If able to access records during Preaudit Phase
this will be considered a part of the Preaudit Phase work. If
records not accessible during Preaudit Phase, reviews will be
completed during the Onsite Phase.
 Training records for employed and contracted medical and
mental healthcare staff

ICF | 14

Policies/Procedures/Other Documents
Subpart E – Assessment for Risk of Sexual Victimization and Abusiveness
§411.41–§411.42
Standard
§411.41Assessment for
risk of sexual
victimization and
abusiveness

Preaudit

Onsite Audit

 Facility policy and/or process for completing
 Sample of case record reviews for compliance with this standard
screening of UCs and any specialized staff training  If specialized training noted, log of staff training and/or
specific to assessment of risk of sexual victimization
documentation to corroborate training attendance
and abusiveness
 Use of screening instrument, if one used (spot check)
 If specialized training noted above, copy of training
 Staff trained to talk to UCs to obtain information listed under this
 Facility policy and/or process for ensuring
standard
appropriate controls on the dissemination within the
care provider facility of responses to questions
asked pursuant to this standard to ensure sensitive
information is not exploited to the UC’s detriment by
staff or other UCs

 Copy of screening instrument used to determine risk
of victimization or abusiveness (should note source
of information indicated in instrument)

§411.42 – Use of
assessment
information

 How the facility utilizes information obtained from
the risk assessment under §411.11 to inform UC
assignment to housing, education, recreation, and
other activities and services
 How assessments and housing assignments are
made for transgender or intersex UCs

 Facility policy and/or process/procedures regarding

 Documentation of UCs with one-on-one supervision over the last
12 months
 Average length of time a UC is under one-on-one supervision
 Documentation of required daily visits from a medical practitioner
or mental healthcare clinician for UCs with one-on-one
supervision

one-on-one supervision

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 15

Policies/Procedures/Other Documents
Subpart F – Reporting
§411.51 – §411.55
Standard
§411.51 – UC
reporting

Preaudit

Onsite Audit

 UC reporting policies, procedures, and documents:













 Check for location of phones, how many are available for this
use, do the phones work, are they accessible without staff
Policies, procedures, documents to identify
assistance, are phones placed where the UC are afforded some
different established procedures allowing for
level of privacy so other children and staff cannot easily listen to
multiple internal ways for UCs to report per the
telephone conversations, etc.
standard
Policy providing ways for UCs to report abuse  Facility options available to UCs for reporting
or harassment to their consular official, ORR’s
headquarters, and an outside entity
Policy and procedures for UCs to access
telephones with free, preprogrammed
numbers for ORR headquarters and the
outside entity designated under §411.51
Policy providing at least one way for UCs to
report abuse and harassment to a public or
private entity or office that is not part of the
agency and ability to receive and immediately
forward UC reports of sexual abuse and
sexual harassment to ORR officials, allowing
UCs to remain anonymous upon request
Documentation of memorandum of
understanding or other agreements with a
public or private entity or office that is not part
of the agency (If there is no memorandum of
understanding [MOU] or agreement,
documentation showing attempts to secure
agreement)
Policy and/or procedures for staff to accept
reports made verbally, in writing,
anonymously, and from third parties
Documentation of verbal reports of sexual
abuse and sexual harassment
Policy and documentation (e.g., staff
handbooks) outlining procedures for staff to
privately report sexual abuse and sexual
harassment of UCs

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 16

Policies/Procedures/Other Documents
Subpart F – Reporting
§411.51 – §411.55
Standard
§411.52 –
Grievances

Preaudit

Onsite Audit

 Policies and procedures for identifying and handling
time sensitive grievances involving an immediate
threat to UC health, safety, or welfare related to
sexual abuse and sexual harassment
 Policies and procedures for reporting identified and
time sensitive grievances involving an immediate
threat to UC health, safety, or welfare related to
sexual abuse and sexual harassment to ORR
 Policies and procedures related to medical
emergencies
 Documentation of written grievance decisions in the
past 12 months

§411.53 – UC
access to outside
confidential
support services

 Memoranda of understanding or other agreements
with community service providers or, if local
providers are not available, with national
organizations. If no agreements, documentation
showing attempts to enter into agreements

 MOUs or other agreements with national organizations

 Facility sexual abuse and sexual harassment
prevention and intervention protocols including
outside agencies
 Policy and/or procedures making local and/or
national organizations information (including contact
information) available to assist UCs who are victims
of sexual abuse and sexual harassment
 Policy and/or procedures enabling reasonable
communication between UCs and local and/or
national organizations available to assist UCs who
are victims of sexual abuse and sexual harassment
§411.55 – UC
access to
attorneys or other

 Policy and/or procedures governing confidential
access to a UC’s attorney or other legal

Preaudit Questionnaire and Requested Documentation Checklist

 Location/rooms/offices designated for attorney-client visitation to
ensure UCs are afforded privacy with legal service provider
(LSP)/attorney during visitation

ICF | 17

Policies/Procedures/Other Documents
Subpart F – Reporting
§411.51 – §411.55
Standard
legal
representatives
and families

Preaudit

Onsite Audit

representative in accordance with care provider’s
attorney-client visitation rules
 Copy of care provider’s visitation rules and attorneyclient visitation rules
 Documentation indicating ORR approval of care
provider attorney-client visitation rules
 Policies and/or procedures governing a UC’s
access to their families, including legal guardians

Policies/Procedures/Other Documents
Subpart G – Official Response Following a UC Report
§411.61–§411.68
Standard
§411.61 – Staff
reporting duties

Preaudit

Onsite Audit

 Relevant approved policy (or policies) governing: (1)  Documentation of notification to the alleged victim’s parents or
the reporting of any knowledge, suspicion, or
legal guardians
information regarding an incident of sexual abuse or  Documentation when notification to the alleged victim’s parents
sexual harassment that occurred while a UC was in
or legal guardians was not safe
ORR care; (2) retaliation against UCs or staff who
 Documentation of notification to the UC’s attorney of record
reported incident; (3) any staff neglect or violation of
within 48 hours
responsibilities that may have contributed to an
incident or retaliation; (4) the reporting by the facility
regarding allegations of sexual abuse and sexual
harassment to the alleged victim’s parents or legal
guardians; (5) victim not consenting to disclosure or
the UC is 14 years of age or older and ORR has
determined the victim is able to make an
independent decision
 Policy governing sharing of allegations of sexual
abuse or sexual harassment to the UC’s attorney of
record

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 18

Policies/Procedures/Other Documents
Subpart G – Official Response Following a UC Report
§411.61–§411.68
Standard
§411.62 –
Protection duties

Preaudit
 Facility policy and/or process to ensure the
protection of UC if a care provider facility employee,
volunteer, or contractor reasonably believes that a
UC is subject to substantial risk of imminent sexual
abuse or sexual harassment

§411.63 –
 How the facility reports allegations of sexual abuse
Reporting to other
or harassment of UCs while located at another care
care provider
provider facility and the referral for investigation
facilities and DHS
process
 Documentation of facility notification to ORR after
receiving the allegation of UC abuse while at
another care provider facility (immediately but no
later than 24 hours)
 Documentation of facility notification to ORR after
receiving an allegation of UC abuse while in DHS
custody (immediately but no later than 24 hours)
§411.64 –
Responder duties

Onsite Audit

 Facility staff first-responder duties and process

 Documentation of allegations that a UC was sexually abused or
sexually harassed while at another care provider facility
 Documentation of allegations that a UC was sexually abused or
sexually harassed while in DHS custody
 Additional documentation of notifications of abuse while placed at
another care facility to verify they occurred no later than 24 hours
from receiving allegation
 Additional documentation of notifications of abuse while in DHS
custody to verify they occurred no later than 24 hours from
receiving allegation
 Documentation of allegations from other facilities and
documentation of response
 Documentation of response to allegations

 Facility policy and/or process for collecting physical
evidence
 In the past 12 months, the number of allegations
that a UC was sexually abused, sexually harassed,
or subjected to inappropriate sexual behaviors

§411.65 –
Coordinated
response

 Facility’s ORR-approved institutional plan to
coordinate actions taken in response to an incident
of sexual abuse by staff first responders, medical
and mental health practitioners, outside
investigators, victim advocates, and care provider
facility leadership

Preaudit Questionnaire and Requested Documentation Checklist

 If the agency is not permitted by law to inform a receiving facility
per the standard, a copy of that law
 Log or other documentation of victim transfers from the care
provider facility because of an allegation of sexual abuse
 Verification of ORR’s approval

ICF | 19

Policies/Procedures/Other Documents
Subpart G – Official Response Following a UC Report
§411.61–§411.68
Standard
§411.66 –
Protection of UCs
from contact with
alleged abusers

Preaudit
 Facility policy and/or process directing the
suspension of ORR and care provider facility staff,
contractors, and volunteers suspected of
perpetrating sexual abuse or sexual harassment
from all duties involving or allowing access to UCs
pending the outcome of the investigation

Onsite Audit
 Log of staff, contractor, or volunteer suspected sexual abuse or
sexual harassment, including date of allegation and date
suspended

§411.67 –
 Facility policy and/or procedures or process
Protection against
protecting all UCs, staff, contractors, or volunteers
retaliation
who report sexual abuse or sexual harassment or
cooperate with sexual abuse or sexual harassment
investigations from retaliation by other UCs, staff,
contractors, or volunteers (including policies on the
monitoring of UC, staff, contractors, or volunteers
following a report and agency response to
suspected retaliation)

 Documentation of any protective measures taken for UCs, staff,
contractors, or volunteers who fear retaliation for reporting sexual
abuse or sexual harassment or for cooperating with
investigations

§411.68 – Postallegation
protection

 Documentation of placement changes of UC victims of sexual
abuse and sexual harassment

 Facility policy and/or process for assignment of UC
victims of sexual abuse and sexual harassment to
the least-restrictive housing option to keep the UC
safe and secure, including policy (or policies)
employing multiple protection measures and
assessment for one-on-one supervision

 Documentation of any monitoring efforts for UCs, staff,
contractors, or volunteers
 Documentation of reports of retaliation and agency response

 Number of UC victims placed on one-on-one
supervision for protection in the last 12 months by
age and gender
 Average length of time for facility to complete a
reassessment

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 20

Policies/Procedures/Other Documents
Subpart I – Intervention and Discipline
§411.81–§411.83
Standard

Preaudit

Onsite Audit

§411.81 Facility policy and/or process regarding violations of  Sample records of termination, resignations, or other sanctions
Disciplinary
agency sexual abuse and sexual harassment
against staff for violating agency sexual abuse and sexual
sanctions for staff
policies
harassment policies from the past 12 months
 Records of disciplinary actions taken against staff for violations of
the agency sexual abuse and sexual harassment policies from
the past 12 months
 Reports to law enforcement and relevant state or local licensing
bodies for violations of agency sexual abuse and sexual
harassment policies
§411.82 –
Corrective action
for contractors
and volunteers

 Facility policy and/or process for requiring that any
contractor or volunteer with a substantiated
allegation of sexual abuse or sexual harassment is
prohibited from working or volunteering at the care
provider facility

 Documentation of referrals to law enforcement and/or relevant
licensing bodies
 Reports of sexual abuse of UCs by contractors or volunteers

 Documentation of remedial measures taken to
prohibit further contact with UCs by the contractors
or volunteers who have not engaged in sexual
abuse or sexual harassment but violated other
provisions within the standard, ORR, and care
provider sexual abuse and sexual harassment
policies and procedures
§411.83 –
Interventions for
UCs who engage
in sexual abuse

 How the facility ensures appropriate UC
interventions are received if minors engage in UCon-UC sexual abuse
 Facility policy and/or procedures for referring
incidents of UC-on-UC abuse to appropriate
investigating authorities

Preaudit Questionnaire and Requested Documentation Checklist

 Documentation of UC-on-UC abuse incidents and facility
response
 Interventions facilitated by external mental health providers (look
at referrals) or could trigger a transfer to other facility
(documentation of transfers)

ICF | 21

Policies/Procedures/Other Documents
Subpart J – Medical and Mental Healthcare
§411.91 – §411.93
Standard

Preaudit

Onsite Audit

§411.91 – Medical
and mental health
assessments;
history of sexual
abuse

 How the facility ensures the immediate referral to a
qualified medical or mental health practitioner of a
UC who has experienced prior sexual victimization
or perpetrated sexual abuse

 Documentation of referrals to a qualified medical or mental health
practitioner of UCs who have experienced prior sexual
victimization or perpetrated sexual abuse

§411.92 – Access
to emergency
medical and
mental health
services

 Facility policy and/or process for UC victims of
sexual abuse to access treatment services
 Policy (or policies) regarding access to treatment
service by UC victims of sexual abuse

§411.93 – Ongoing  Facility policy and/or procedures for the provision of
medical and
ongoing medical and mental health evaluations and
mental healthcare
treatment to all UCs victimized by sexual abuse or
for sexual abuse
sexual harassment while in ORR care and custody
and sexual
 Facility policy and/or procedures for the provision of
harassment
ongoing medical and mental health services to all
victims and
UCs victimized by sexual abuse or sexual
abusers
harassment while in ORR care and custody
 Facility policy and/or procedures ensuring female
UC victims of sexual abuse by a male abuser while
in ORR care and custody are offered pregnancy
tests, as necessary
 Facility policy and/or procedures regarding positive
pregnancy tests of female UC victims of sexual
abuse by a male abuser while in ORR care and
custody

 Documentation of health evaluation no later than 72 hours after
the referral for medical follow-up is initiated
 Documentation of mental health evaluation no later than 72
hours after the referral for mental health follow-up is initiated
 Sample of secondary materials (e.g., form, log) documenting
access to required services per the standard

 Log of UCs victimized by sexual abuse or sexual harassment
while in ORR care and custody
 Documentation corroborating receipt of medical and mental
health evaluations and ongoing treatment
 Documentation corroborating offer of pregnancy tests to female
UC victims of sexual abuse by a male abuser while in ORR care
and custody
 Documentation corroborating offer of sexually transmitted
infection (STI) testing to UC victims
 Documentation of mental health evaluations within 72 hours of
learning about a UC-on-UC abuser
 Additional medical/mental health secondary forms/logs
describing access to services
 Sample of secondary materials (e.g., form, log, handout)
documenting access to required services per the standard

 Facility policy and/or procedures ensuring UC
victims of sexual abuse that occurred in ORR care

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 22

Policies/Procedures/Other Documents
Subpart J – Medical and Mental Healthcare
§411.91 – §411.93
Standard

Preaudit

Onsite Audit

and custody are offered tests for sexually
transmitted infections
 Facility policy and/or procedures ensuring UC
victims are provided access to treatment services
regardless of whether the victim names the abuser
or cooperates with any investigation arising out of
the incident
 Facility policy and/or procedures regarding
conducting a mental health evaluation of all known
UC-on-UC abusers within 72 hours of learning
about such abuse and/or such abuse history and
offering of treatment deemed appropriate by mental
health practitioners

Preaudit Questionnaire and Requested Documentation Checklist

ICF | 23