Attachment 1 for NonSub Change to Form M-3-A

Attachment 1
FFS Site Visit Form Revisions
Revised Form Section	Revised Form Field Label	Revised Form Progressive Disclosure	Modifications to Existing Form	In the existing form?	Existing Form Field Label
			Removed	Yes	This form will record you name, please fill in your name.
Visit Information	ORR Region	No	No modifications	Yes	1. ORR Region
Visit Information	Program Name	No	No modifications	Yes	2. Program Name
Visit Information	Level of Care	No	No modifications	Yes	3. Level of Care
Visit Information	ORR Representative Name	No	No modifications	Yes	4. ORR Representative Name
Visit Information	Date of Visit	No	Rephrased	Yes	5. Report Date
Site Visit Walkthrough	Did the program have a Facility Inspection Checklist for a Child Friendly Environment completed?	No	No modifications	Yes	6. Did the program have a Facility Inspection Checklist for a Child Friendly Environment completed?
Site Visit Walkthrough	What date was it completed?	Yes	Rephrased	Yes	7. Please note date it was completed
Site Visit Walkthrough	Did the Checklist for a Child Friendly Environment meet all satisfactory markings (i.e., was it all marked yes)?	No	No modifications	Yes	8. Did the Checklist for a Child Friendly Environment meet all satisfactory markings (i.e., was it all marked yes)?
Site Visit Walkthrough	Note any deficiencies:	Yes	Rephrased	Yes	9. Please note any deficiencies
Site Visit Walkthrough	Does the program have working video cameras and are they reviewed by the program?	No	No modifications	Yes	10. Does the program have working video cameras and are they reviewed by the program?
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes	11. If No, a comment is required:
Site Visit Walkthrough	Are all entry and exit alarms tested to ensure they work (including windows and doors)?	No	Rephrased	Yes	12. Are all entry and exit alarmstested to ensure they work (includes windows and doors)?
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes	13. If No, a comment is required:
Site Visit Walkthrough	Do all entries and exits have safety measures? (e.g., perimeter barriers, perimeter lighting, alarms to note for entry/exit without permission)? Note: FFS can ask to see these safety measures.	No	Rephrased	Yes	14. Do all entries and exits have safety measures? (perimeter barriers, perimeter lighting, alarms to note for entry/exit without permission)?
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes	15. If No, a comment isrequired:
Site Visit Walkthrough	All required bulletin board postings to educate youth about sexual abuse, sexual harassment, and reporting are posted in ALL required areas in language child understands?	No	Rephrased	Yes	16. All required bulletin board postings to educate youth about sexual abuse, sexual harassment, and reporting are posted in ALL required areas in language UC understands?
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes	17. If No, a comment is required:
Site Visit Walkthrough	Are Garza Notices and Infographics posted?	No	No modifications	Yes	57. Are Garza Notices and Infographics posted?
Site Visit Walkthrough	A comment is required:	Yes	New	No
Site Visit Walkthrough	Required pre-programmed phone is accessible to children, private, and correctly preprogrammed for child to report sexual abuse, sexual harassment, and sexually inappropriate behavior? All three must be compliant to indicate “Yes".	No	Rephrased	Yes	18. Required Preprogrammed phone is accessible to UC, private, and correctly pre-programmed for UC to report sexual abuse, sexual harassment, and sexually inappropriate behavior (all three must be compliant to indicate “yes")
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes
Site Visit Walkthrough	Overall appearance of the program is neat, organized, and clean that does not present any health or safety concerns?	No	No modifications	Yes	20. Overall appearance of the program is neat, organized, and clean that does not present any health or safety concerns?
Site Visit Walkthrough	A comment is required:	Yes	Rephrased	Yes	21. If No, a comment is required:
Site Visit Walkthrough	Is the program in compliance with all staffing ratio requirements?	No	No modifications	Yes	22. Is the program in compliance with all staffing ratio requirements?
Site Visit Walkthrough	A comment is required:	Yes	New	No
Site Visit Walkthrough	Are there staffing concerns?	No	No modifications	Yes	23. Are there staffing concerns?
Site Visit Walkthrough	Please confirm you elevated this to the Project Officer for resolution or to address child capacity.	Yes	Rephrased	Yes	24. If Yes, please confirm you elevated this to the Project Officer for resolution or to address UC capacity.
Site Visit Walkthrough	Observations(e.g., recent improvements, recent repairs,shade for kids outside, old/new furniture, etc.):	No	Rephrased	Yes	25. Observations (recent improvements, recent repairs, shade for kids outside, old/new furniture, etc.)
Site Visit Walkthrough	Concerns(focus on safety issues for child or staff - blind spot supervision, etc.):	No	Rephrased	Yes	26. Concerns(focus on safety issues for UC or staff - blind spot supervision, etc.):
Child Interviews	Add Child Interview No children were interviewed on this visit. Reason	No	Rephrased	Yes	27. Please note the number of children in the group interviewed.	Instead of asking how many children were interviewed, the user will have the option to press a button to add any number of interviews that they wish. If no children are interviewed, the user can select the "No children…" checkbox and enter an explanation in the Reason text box.
Child Interviews	Estimated age range of the child(ren).	No	Rephrased	Yes	28. Please note the estimated age range of the group of chidren you interviewed
Child Interviews	Interpreter used?	No	Rephrased	Yes	29. Interpreter used by FFS or CFS
Child Interviews	Provide comment:	No	Rephrased	Yes	30. If Yes, note language
Child Interviews	Does the child have the opportunity for daily Recreation (large and small muscle)? Refer to Policy 3.3.8	No	Rephrased	Yes	31. Does the UC have the opportunity for daily Recreation (large and small muscle)?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	32.Comments
Child Interviews	Does the child have access or a choice to participate in preferred Religious Services? Refer to Policy 3.3.7	No	Rephrased	Yes	33. Does the UC have access or a choice to participate in preferred Religious Services?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	34. Comments
Child Interviews	Does the child have Leisure Time? Refer to Policy 3.3.8	No	No modifications	Yes	35. Does the UC have Leisure Time?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	36. Comments
Child Interviews	Does the child meet with his/her CM once per week? Refer to Policy 2.3.2	No	Rephrased	Yes	37. Does the UC meet with his/her CM once per week?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	38. Comments
Child Interviews	Does the child meet with his/her Clinician for one hour sessions per week? Refer to Policy 3.3	No	Rephrased	Yes	39. Does the UC meet with his/her Clinician for one hour sessions per week?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	40. Comments
Child Interviews	Does the child have a Clinical Group? Refer to Policy 3.3	No	No modifications	Yes	41. Does the UC have a Clinical Group?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	42. Comments
Child Interviews	Are there Community Meetings the child can participate in? Refer to Policy 3.3	No	No modifications	Yes	43. Are there Community Meetings the UC can participate in?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	44. Comments
Child Interviews	Does the child get at least two calls per week with his/her parent and/or sponsor? Refer to Policy 3.10, 3.3.7	No	No modifications	Yes	45. Does the UC get at least two calls per week with his/her parent and/or sponsor?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	46. Comments
Child Interviews	Are Sexual Abuse Hotline pre-programmed phones accessible to the child at any time? Refer to Policy 4.10.1, 4.10.6	No	No modifications	Yes	47. Are Sexual Abuse Hotline pre-programmed phones accessible to the UC at any time?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	48. Comments
Child Interviews	Is the child aware of the legal services provider and his/her access to the LSP? Refer to Policy 3.3	No	No modifications	Yes	49. Is the UC aware of the legal services provider and his/her access to the LSP?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	50. Comments
Child Interviews	Does the child understand his/her family reunification case? Refer to Policy 2.3.2	No	No modifications	Yes	51. Does the UC understand his/her family reunification case?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	52. Comments
Child Interviews	Does the child attend school/education classes for at least 6 hours per day Monday-Friday? Refer to Policy 3.3.5	No	No modifications	Yes	53. Does the UC attend school/education classes for at least 6 hours per day Monday-Friday?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	54. Comments
Child Interviews	Is the child aware of how to file a grievance? Refer to Policy 4.10.1, 3.2.2	No	No modifications	Yes	55. Is the UC aware of how to file a grievance?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	56. Comments
Child Interviews	Do you feel safe?	No	No modifications	Yes	58. Do you feel safe?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	59. Comments
Child Interviews	Do you like living at this program?	No	Rephrased	Yes	60. Do you like living at this program?
		No	Removed	Yes	61. If Yes, wht is it that you like about the program?
Child Interviews	Provide comment:	Yes	Rephrased	Yes	62. If No, what is it that you don't like and what would you like to see changed?
Child Interviews	Who would you ask for help if you have a problem while living here at the program?	No	Rephrased	Yes	63. Would you ask for help if you have a problem while living here at the program?
Child Interviews	Do you have anything else I have not asked you about that you want to tell me?	No	No modifications	Yes	64. Do you have anything else I have not asked you about that you want to tell me?
Child Interviews	Do I need to follow up on any items that came up during the interview?	No	Rephrased	Yes	65. Please mark Yes or No if you need/want to follow up on any items that came up during the interview?
Child Interviews	What items require follow up?	No	Rephrased	Yes	66. If yes, what items require follow up?
Trends & Follow-up	Trends/Comments: Please provide a narrative discussion of your main findings and areas of potential concern.	No	No modifications	Yes	65. Trends/Comments: Please provide a narrative discussion of your main findings and areas of potential concern.
Trends & Follow-up	Did you identify any potential issues to monitor or for additional follow up?	No	No modifications	Yes	66. Did you identify any potential issues to monitor or for additional follow up?
Trends & Follow-up	List any specific issues that need to be reviewed again during the next site visit?	Yes	No modifications	Yes	67. If yes, list any specific issues that need to be reviewed again during the next site visit?
Trends & Follow-up	Follow up: List any follow up conducted on any previous concerns (Corrective Actions, SA/SIRs, Emergency SIRs, Notice of Concern from PRS provider, any outcomes, or issues from a previous site visit by the FFS, CFS, or Monitoring Team)	No	No modifications	Yes	68. Follow up: List any follow up conducted on any previous concerns (Corrective Actions, SA/SIRs, Emergency SIRs, Notice of Concern from PRS provider, any outcomes, or issues from a previous site visit by the FFS, CFS, or Monitoring Team)
Trends & Follow-up	Action Items: List any plans to address newly identified or remaining concerns. Please include who you have notified if you are not the responsible party for follow up or the next site visit and the due date.	No	Rephrased	Yes	69. Action Items: List any plans to address newly identified or remaining concerns. Please include who you have notified if you are not the responsible party for follow up or the next site visit.