10 ANNEXES

10.1 LIST OF ANNEXES

No.	Forms	Description	Page
	SUKA Society Child Protection Policy and Agreement	Statement of intent and commitment to ensuring all minor clients of SUKA Society are protected and safeguarded by all parties who come into contact with children. This is to ensure all staff respect the duty of care owed to each minor client.	76
	Confidentiality Agreement	Written agreement signed by SUKA Society and each staff member to ensure sensitive client information is kept confidential.	82
	Supervision Tool and Case Management Checklist for Case Managers	Checklist for Case Managers to assess if they are carrying out their functions and responsibilities adequately. Also a tool for Case Supervisors to provide constructive feedback to Case Managers. All information to be kept confidential.	83
	a) Suggested General Self-care Framework b) Suggested Debriefing Framework after an Incident	A suggested framework as part of organization self-care for staff to reflect on self-care practices generally, or after a critical incident.	85 86
	Complaints/Filing Grievances Form	Formal and confidential complaints mechanism for staff, clients and partners to raise any allegations/observation of misconduct, violation of child protection polices, or dissatisfaction of services by the agency/staff.	87
	Do’s and Don’ts of Child Friendly Interviewing	A non-exhaustive list of child-friendly techniques when interviewing children. Adapted from the United States Conference of Catholic Bishops Migration and Refugee Services.	89
	Guide to Working with Interpreters	A suggested guide for Case Managers, prior to engaging an interpreter in case work or during intake interviews.	90
	a) Government/UN Agency Referral Form b) NGO/CBO Referral Form	Form to be filled by referral agency. The forms include background information on the child, caregiver, and circumstances of referral.	93 96
	a) Programme Screening Tool b) UASC Arrest and Detention Screening Tool	Screening form to assess if UASC referrals falls within the scope of the organization’s programme Screening form to be used for UASC currently in detention for prioritization of release.	99 101
	Introductory Brief for Case Manager for the Intake Interview	Sample introductory brief for SUKA Society Case Managers prior to an intake interview.	104
	Client Needs and Risks Intake Form	Assessment of needs and risks across pertinent life domains including living conditions, family and caregiver relationships, trauma experienced, reasons for migration, health and mental health needs, education and social support systems, etc.	105
	Heightened Risk Rating Form	An assessment of specific heightened risk factors with a rating scale.	111
	Programme Admission Form	Form to be filled in by the Case Manager for discussion during a Case Conference.	116
	Child Trauma Screening Questionnaire	A 10-item self reporting questionnaire to identify children at risk of developing PTSD following a traumatic event such a detention, persecution from country of origin, etc.	119
	Client Programme Consent Form	Consent form to be signed by the caregiver and/or the child to agree to be committed and willing to participate in the case management and intervention process and to share confidential information.	120
	Client Consent Form – Sharing of Information with other Agencies	Consent form to be signed by the caregiver and/or the child for SUKA Society to disclose relevant case information to service providers working on the case.	123
	Full Client Individualized Care Plan Template (Excel document)	Full Excel document template to monitor progress of client’s care plan.	124
	Goals Development/Care Plan Template	To be filled collectively by the Case Managers and the client with both parties agreeing on the goals, strategies, outcomes, timelines and persons involved. This Care Plan will also be adapted and changed depending on the clients’ progress and following monitoring exercises.	125
	Sample Goals Development/Care Plan	A sample completed Care Plan for a child.	127
	Intervention Referral Form	A form used for referrals to relevant service providers for intervention.	129
	Safety Plan and Care Provider Emergency Planning Template	A template to help a care provider to plan for the care of the child should he/she be detained by immigration authorities or become incapacitated.	130
	Tracing, Placement and Family Reunification Tool	Data collection tool to coordinate services with implementing partners for tracing, restoring family links and placement. Allows for information to be collected systematically and shared with all agencies involved in a client’s case.	132
	Sample Independent Living House Rules	Suggested house rules for UASC placed in independent living homes.	136
	Sample Physical Health Assessment Checklist	Suggested checklist for initial physical and mental health assessment for referral to relevant service providers.	138
	Client Medication Chart/Tracker	Suggested chart to track a child’s medication needs.	142
	Home Visit Checklist	A checklist for Case Managers to complete during a home visit – assessment of living conditions and caregiver relationships. A specific checklist within a foster care arrangement has also been developed.	143
	Case Notes/Monthly Home Visit Template	Sample general case notes template for Case Managers to collect client data. All case notes must be stored appropriately.	144
	Progress Notes Template	Sample progress notes template for Case Managers to document client strengths, observations, assessments and plans following a home visit/interview.	149
	Client Exit Form	To be filled by the client when case management services are terminated, or upon achieving case resolution.	150
	Client Feedback Form	To be conducted during the termination phase to obtain anonymous feedback from clients on the services and the overall case management process for SUKA Society to improve services.	153
	Sample Termination Letter	Sample letter when a client terminates or exits from the Programme.	155
	Sample Recommendation Letter	Sample recommendation letter for clients for job or school enrolment.	156
Community Placement: Foster Care
	Key Foster Care Stakeholder Roles and Responsibilities	Non-exhaustive list of roles and responsibilities of key foster care stakeholders – namely the foster parents and foster care personnel.	157
	Minimum Standards of Care	Prescribed list of minimum standards of care in foster care arrangements.	159
	Foster Parents Application Form	Suggested application form for potential foster parents.	161
	Foster Parents Reference Form	Suggested form for referees to complete as part of the selection process of suitable foster parents.	164
	Basic Screening Criteria for Foster Parents in the Programme	Factors to be considered when selecting a foster parent.	166
	Foster Parents Intake Form	Interview form when interviewing potential foster parents and assessment of potential foster parents’ living conditions.	167
	Trainers Report	Suggested format for trainers to complete a report following training of potential foster parents.	172
	Home Study Report	Report to be completed by the foster care personnel to be presented to the Selection Committee to assess the suitability of potential foster parents.	174
	Foster Care Agreement Form	Agreement form for the organization, foster parents and the child with regards to the placement.	181
	Admission Appeal Form	Appeal form for the foster parents and/or the child to appeal decisions by the organization.	184
Additional Resources
	Internal Monitoring and Evaluation Framework	Monitoring and evaluation tool for the programme.	185
	Client Needs and Risks Intake Summary and Proposed Case Action Plan	Summary of information obtained from the Client Needs and Risks Intake Form. To be filled in by the Case Manager to aid risk identification and development of goals.	192

10.2 Annex 1: SUKA Society Child Protection Policy and Agreement [Download]

Part 1: Introduction

SUKA Society is committed to safeguarding children from harm by striving to create a safe and positive environment for children, and we take our duty and responsibility of care seriously. Protecting children is a mandatory part of SUKA Society being able to achieve its mission.

SUKA Society will achieve an agenda of safeguarding children by being:

• PREVENTATIVE: In organizing programmes and activities, SUKA Society ensures measures to minimize the risk of harm to children.

• REACTIVE: SUKA Society representatives must take appropriate action to address concerns and respond promptly and adequately.

This policy is based on child rights conventions, Malaysian legislation and internationally recognized good practices. It also provides a framework of principles, standards and guidelines on which to base individual and organizational practice.

THE PURPOSE AND SCOPE OF THE POLICY

This policy is designed to provide guidance to all SUKA Society representatives, whether in Malaysia or elsewhere. Its purpose is to help SUKA Society representatives to:

• Understand the importance of child protection issues.

• Know their responsibilities and ensure compliance under legal and policy obligations within and outside their work environments at all times.

• Uphold the dignity and respect of children.

• Ensure a safe environment for children through preventative measures.

• Provide guidance on child protection issues and good practices.

Part 2: Prevention of Abuse

INTRODUCTION

This section covers a range of procedures and actions that should be undertaken to safeguard children and prevent abuse taking place. It consists of checklists to ensure the safe selection and recruitment of all SUKA Society representatives, the reduction of risks when working with partners and alliances, and a strict Code of Conduct of acceptable and unacceptable behaviour when having direct and indirect contact with children.

1. RECRUITMENT AND SELECTION

According to the best practice approach, SUKA Society carries out a range of required pre-employment checks. The purpose of this policy is to ensure effective, fair and consistent recruitment processes for all representatives recruited in Malaysia. The guidelines help to:

• Deter applications from unsuitable people who may seek to gain access to children through SUKA Society’s activities.

• Ensure that those who are successful in their applications are deemed safe to work with children.

SUKA Society will ensure its recruitment and selection processes for staff and representatives comply with the criteria set out below:

RECRUITMENT AND SELECTION POLICY

• Candidates should be aware that applying for the position may entail a police record verification.

• Candidates should submit and sign their application form.

• Candidates will have their employment history verified, including the investigation of any gaps between jobs.

• Candidates will have their identity verified with original documents.

• Candidates will be required to complete a SUKA Society Self-declaration Form.

• Candidates will be asked specific questions related to child protection and appropriate interactions with a child during the interview.

• Candidates should provide two or three satisfactory referees (depending on the level of contact with children that the position entails).

• Referees will be queried about the candidate’s experience in working with children and asked to disclose any concerns that they may have about the candidate’s suitability to work with children.

2. REQUIREMENTS FOR PARTNERS AND VOLUNTEERS

SUKA Society expects all partners and volunteers working with SUKA Society to consistently apply good practices of child protection in all activities involving children. All child protection concerns must be reported to SUKA Society immediately. Necessary steps will be undertaken to address any child protection concerns and any potential long-term effects on the child. All partners and volunteers should:

• Be aware and agree to abide by this policy, particularly the Code of Conduct.

• Complete and sign the Volunteer Form.

• Always be accompanied by a SUKA Society staff.

3. CODE OF CONDUCT

All SUKA Society representatives are required to understand and abide by a Code of Conduct that outlines rules of appropriate and proper behaviour when working with children. This Code of Conduct is designed primarily to protect children; however, it also serves to protect representatives from false accusations.

Acceptable Behaviour and Conduct:

SUKA Society representatives should:

• Be committed to creating a culture of openness and mutual accountability at work places to enable all child protection issues or concerns to be raised and discussed, and where abusive behaviour can and must be challenged.

• Take steps to empower children by informing them of what is acceptable and unacceptable behaviour of adults.

• Encourage children to safely raise their concerns about staff or others, if there is a need to.

• Conduct a risk analysis when organizing activities and programmes involving children and plan for ways of mitigating risks.

• Ensure that the risks of working alone are minimized by ensuring the “two-adult” rule and that they are always visible to others when working with children. The “two-adult” rule requires a minimum of two adults to be physically present when working with an individual child or a group of children.

• Ensure physical contact is at all times appropriate and not an invasion of the child’s privacy.

• Use positive, non-violent methods to manage children’s behaviour.

• Raise any concerns of inappropriate behaviour by any adult or child immediately.

Unacceptable Behaviour:

At all times, staff and representatives of SUKA Society within and outside their work environments, must not:

• Develop physical or sexual relationships with children who they interact, engage or work with.

• Behave physically in a manner which is inappropriate or sexually provocative.

• Spend excessive time alone with a child, away from others, behind closed doors or in a secluded area.

• Take a child to their home or visit a child at his/her home where they may be alone with the child.

• Allow a child to stay overnight at their home unsupervised.

• Do things of a personal nature for a child that he/she could do for himself/herself.

• Engage in sexual activity with a child regardless of the local age of consent.

• Be intoxicated, under the influence of alcohol or drugs prior to assuming responsibility for any child.

• Hit, or otherwise physically assault, or physically abuse a child.

• Act in ways that may be abusive or may place a child at risk of abuse.

• Use language, make suggestions or offer advice which is inappropriate, offensive or abusive.

• Condone or participate in behaviour with children which is illegal, unsafe or abusive to the child.

• Act in ways intended to shame, humiliate, belittle or degrade children, or otherwise perpetrate any form of emotional abuse.

• Show favour to a particular child to the exclusion of others (for example, promising a child gifts and enticements).

• Exploit children to work (e.g. domestic servants) or for sexual purposes.

• Conduct or be part of harmful traditional practices, spiritual or ritualistic abuse.

4. COMMUNICATION REGARDING CHILDREN

SUKA Society is committed to ensuring that all interviews and footage of children are undertaken with sensitivity in order to safeguard the child’s right to dignity, confidentiality and privacy. Where possible, children should be primed prior to being interviewed.

Children who are not being interviewed or named can be photographed in public places (e.g. in the street) without needing written consent. Verbal consent from these children can be sought, where practical.

Pictures of children should always be decent and respectful. Consent to use information obtained in interviews and/or images of children who have been interviewed should be obtained from children themselves (if they are of an age, understanding and possess the maturity to do so) and from their parents and/or guardians. Consent can also be obtained retrospectively, after the interview.

When SUKA Society is required to use images or information about children, they should assess the risks of harm or stigma to the child according to the following guidelines:

• Level 1 (Low risk of harm or stigma)

  Faces, first names and geographical location may be revealed.

• Level 2 (Medium risk of harm or stigma)

  Faces, pseudonyms and vague geographical location may be revealed.

• Level 3 (High risk of harm or stigma)

  Faces and visuals to be concealed, pseudonyms to be used and locations to be changed.

Third party individuals or organizations requesting the use of SUKA Society’s resources on children, such as personal information of children, videos or photographs, will be required to sign an agreement with SUKA Society as to the proper use of such materials. Failure to adhere to the terms could result in the termination of permission.

Part 3: Intervention

This section looks at what actions need to be taken when a child informs you that they have been abused. It highlights the indicators of abuse so that you are aware of what to look for when a child discloses abuse. It also looks at the types of disclosure you may expect, and what the steps are for managing the disclosure.

INDICATORS OF ABUSE

Representatives of SUKA Society should be aware of some of the indicators of abuse and neglect, so that concerns can be raised. These signs and indicators should never be ignored, but they also do not always mean that a child has been abused, as other explanations are possible.

DISCLOSURE OF ABUSE

SUKA Society is committed to swiftly investigating disclosures (i.e. when a specific allegation of abuse is made against a named individual) and suspicions (i.e. when a concern is expressed or observed that abuse may have taken place). At all times, the welfare of the child is of paramount consideration.

MANAGING DISCLOSURES FROM A CHILD

• Listen to the child and do not reject what he/she says. Allow the child to speak freely, only asking open questions to establish the basic facts or nature of the complaint.

• Reassure the child that they have done the right thing by disclosing the abuse. Take the allegation seriously.

• Avoid promising the child total confidentiality as abuse concerns child protection and the child may still be at risk.

• Explain your responsibility to pass the information to the authorized officer in charge of child protection (if unavailable, then to the relevant government agency).

• Avoid gossip and making assumptions. Additionally, avoid investigating, informing or confronting the Subject of Complaint or alleged perpetrator(s).

REPORTING MECHANISM

There are three types of reports that can be made:

• Reports concerning a staff or representatives of SUKA Society.

• Reports concerning a partner or a volunteer.

• Reports relating to child abuse in the community or an institution.

RESPONSIBILITY TO REPORT AND DUTY TO COOPERATE

Identities of informants should be kept confidential, particularly where there may be safety issues. The Subject of Complaint (or alleged perpetrator) and all witnesses must cooperate with the internal and external investigations and hearings. This will ensure that they will be provided an opportunity to present their side of the story.

DUTIES OF THE AUTHORIZED OFFICER IN CHARGE OF CHILD PROTECTION

SUKA Society will convene a Child Protection Meeting within 24 hours of receiving a complaint with regards to this policy or information on an allegation of child abuse, to obtain further information, assess the concern, decide on the further action needed, and inform the authorities, if necessary.

Appoint and delegate the investigation to a Child Protection Investigating Officer if the matter is in breach of this Policy and therefore requires further investigation.

Monitor the progress of the investigation and give guidance as appropriate.

Make recommendations pending the outcome of the child protection meeting and investigations carried out based on what is in the best interest of the child/children.

Part 4: Implementation, Monitoring and Review of Policy

This section looks at how the policy can be communicated to everyone who represents SUKA Society to ensure that they understand their roles and responsibilities. SUKA Society will take the following measures to support effective implementation, monitoring and review of this policy:

• Child protection will be communicated as ‘everybody’s responsibility’.

• Emphasis will be placed on managers’ responsibilities to ensure that protection measures are put in place.

• Recruitment procedures will include police and reference checks to establish suitability for working with children.

• Orientation of representatives will include mandatory briefing and training on child protection issues.

• The wide distribution and dissemination of a summary of the policy with electronic access to the full policy in the local language.

• Prior to their appointment, all representatives will be required to sign an acknowledgement and consent form to agree to the terms of this Policy.

• Integrating child protection measures in all core internal processes (e.g., planning, programme design, risk management, monitoring and accountability mechanisms, performance management, etc.).

• Reported incidences will be recorded and lessons learnt from these incidences must be incorporated into the Child Protection Policy to prevent any repeat of such incidences.

• The Child Protection Policy must be reviewed every three years or sooner, as and when required.

For further information regarding our child protection policy, please write to enquiry@sukasociety.org.

Statement of Commitment or Agreement to SUKA Society’s Child Protection Policy

1. I have read and understood the standards and guidelines outlined in this Child Protection Policy. I have also been given a copy of SUKA Society’s Child Protection Policy.

2. I agree with the principles contained therein, accept the importance of implementing child protection policies and practices, and will abide by these policies and practices while associated with SUKA Society.

3. I have not been accused or convicted of any offence involving physical or sexual abuse of children or young people.

4. I understand that if a complaint is brought against me regarding the abuse of children while engaged in SUKA Society’s activities, the allegation will be thoroughly investigated, in cooperation with the appropriate authorities.

Name: _________________________________________________________

Signature: ______________________________________________________

Date: __________________________________________________________

Declaration of Criminal Convictions

Have you ever been convicted of a crime? Yes ________ No ________

If yes, please provide details of all criminal convictions, including those considered “spent”, and declare any previous investigations or allegations made against you.

_____________________________________________________________________________________________________________________________________________________________________________________________________________________________

Note: This will be kept confidential by the designated staff of SUKA Society, who will assess whether you pose any risk in relation to child protection.

10.3 Annex 2: Confidentiality Agreement [Download]

Statement of Confidentiality

I, (print name) __________________________________, understand that in the course of my relationship with SUKA Society, I may learn of certain facts about individuals serving, and other clients being served by SUKA Society that are of a highly personal and confidential nature. Examples of such information may include, but is not limited to, client identity, medical condition and treatment, finances, living arrangements, prior abuse, exploitation or trauma, legal status, employment status, sexual orientation, addresses, telephone numbers, etc.

I understand that all such information must be treated confidentially and that any breach may result in my termination of services by SUKA Society.

I agree not to disclose any information of a personal and confidential nature to any person not affiliated with SUKA Society and/or authorized by SUKA Society, without specific permission.

I agree that I may use confidential information, only to the extent necessary to perform my authorized duties, and in doing so, will uphold the best interest of the client. I agree not to use any confidential information in a way which would be harmful to the client or to SUKA Society.

I agree to ensure that all confidential documents will be stored in the manner prescribed in SUKA Society’s Community Placement and Case Management Manual.

I agree to meet and talk with assigned Case Managers or Case Supervisors in situations where I have questions about confidentiality, or possible violations of confidentiality.

I agree, that when my relationship with SUKA Society ends, I will continue to honour the confidentiality of any client specific information that I may have learnt.

______________________________________

Signature of Interpreter/Volunteer Date:

__________________________________

Name of Interpreter/Volunteer

______________________________________ ___________

Signature of Case Manager/Case Supervisor Date:

__________________________________________________

Name of Case Manager/Case Supervisor

10.4 Annex 3: Supervision Tool and Case Management Checklist for Case Managers [Download]

Supervision Tool and Case Management Checklist
The Case Supervisor should use this checklist as part of ongoing case supervision. The Case Supervisor should review the Case Manager’s practice on an individual case by asking the Case Manager if he or she completed the tasks listed for each step of the case management process. This checklist also provides an opportunity for Case Managers to monitor his/her own practices.
CREATE A CLIMATE OF TRUST, SUPPORT AND CARE
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Stay calm and comforting throughout the child’s care and treatment?
Communicate with the child using simple, clear, non-blaming language?
Tell the child he/she is strong and brave to speak about what has happened?
Tell the child it is not his/her fault and that he/she is not to blame for what happened?
Appropriately include the child’s ideas, views and opinions throughout his/her care and treatment?
Try not to overwhelm the child with too much information and help the child prioritize his/her needs?
Establish a positive relationship with the child’s caregivers or foster parents?
Respect confidentiality and privacy of the child and his/her family?
INTRODUCTION/ENGAGEMENT AND INTAKE AND ASSESSMENT STEPS
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Explain to the child in simple, clear terms about case management services and confidentiality?
Obtain informed consent from the child and/or caregiver or foster parents appropriately?
Conduct a safe and supportive interview (following the best practices for communication/interviewing)?
Collect only the details of the incident relevant to helping the child and his/her family?
Assess the child’s safety, stability, permanency and well-being needs appropriately?
Complete the correct forms and documentation?
CASE ACTION PLANNING AND IMPLEMENTING THE ACTION PLAN STEPS
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Develop treatment goals and an action plan based on the assessment of needs?
Involve the child’s views and opinions in decision-making according to best practices?
Involve the caregiver or foster parents in the child’s care plan (where appropriate)?
Ensure the child’s best interests (e.g., making sure any actions taken will safeguard physical and emotional safety) when planning action steps?
Explain options for service providers to help meet the child’s needs?
Ask the child and caregiver how much and how information should be shared during the referral process?
Obtain informed consent for referrals?
Coordinate the child’s needs through safe and appropriate referrals (e.g., accompany the child)?
Implement mandatory reporting procedures (if applicable)?
Consult with the Case Supervisor on urgent safety concerns raised?
Make a follow up plan or appointment following an incident?
Complete the correct forms and documentation?
CASE FOLLOW UP
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Meet with the child at the requested time and location for the follow up appointment?
Review the initial case goals and action plan to assess the status of the child’s needs being met?
Re-assess the child’s needs during the follow up to see if new issues or needs have surfaced?
Develop a revised action plan to address new risks or needs of the child?
Obtain informed consent for any additional service providers who will be brought into the child’s care?
Make another follow up appointment with the child and/or caregiver or foster parents?
Complete the correct forms and documentation?
CASE CLOSURE
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Assess, with the child and/or caregiver or foster parents, if all needs have been met and no further case management is needed?
Review the safety plan in place?
Explain to the child and the caregiver or foster parents the termination process and where to seek further assistance if necessary?
Complete the appropriate case documentation?
OVERALL CASE MANAGEMENT PROVIDED
Did the Case Manager…	Yes	No	N/A	Supervisor Comments
Follow the procedures and processes prescribed in the Manual?
Complete the case management steps and procedures accordingly?
Receive advice and supervision well?

10.5 Annex 4a: Suggested General Self-care Framework [Download]

The purpose of this self-care framework is to provide the organization with a suggested process to reflect on practice, identify good practices, and areas for general improvements. This framework is merely a suggestion and staff should use a variation of tools¹⁵ to engage in debriefing. It is also encouraged that group debriefing be conducted to enable experiential learning and reflection on practice. Below is a suggested framework to lead a self-care exercise:

Reflective Areas	Description
Introduction	Identify parameters for discussion and establish the importance of self-care. Establish confidentiality and safe space to share
Identifying what is most troubling/challenging	Identify two events/issues which were most stressful, upsetting or troubling over the last few months.
Identifying what has been some positive experiences	Identify two experiences which have been most positive or rewarding over the last few months.
Acknowledging stress related symptoms	Acknowledge the stressors on the job and in your personal life.
Normalizing and teaching	Identify ways to mitigate stress, and explore new strategies to manage stress.
Closing	Summarize follow up and areas of review for the next self-care session.

1. What is the purpose of this exercise?

2. Why is it an important exercise?

3. Facts: What event/issue have been most challenging? What about the event/issue has made it challenging?

4. Feelings: How did the event/issue make you feel?

5. Thoughts: How did you perceive the event/issue?

6. Behaviour: How did you react before, during, and after the event/issue?

7. Facts: What are some positive experiences over the last few months?

8. Feelings: How did the positive experience make you feel?

9. Thoughts: How did you perceive the experience?

10. Behaviour: How did you react before, during, and after the experience?

11. Are you experiencing any stress related symptoms – physically, mentally, or emotionally? What are these symptoms?

12. How have you dealt with or expressed these symptoms?

13. What methods can you use to reduce stress?

14. What support is available?

15. What are areas to work on, to follow up, and review before the next session?

10.6 Annex 4b: Suggested Debriefing Framework after an Incident [Download]

The purpose of this debriefing framework is to provide the organization with a suggested process to reflect on practice, identify good practices and areas for improvement, as well as for Case Managers to reflect on a particular critical incident. This framework is merely a suggestion and staff should use a variation of tools¹⁶ to engage in debriefing. It is also encouraged that group debriefing be conducted to enable experiential learning and reflection on practice.

Below is a suggested framework to lead debriefing discussions:

Reflective Questions	Description
What happened?	Describe the critical incident, particular event or issue at hand. Think of both positive and negative events that have happened over a prescribed period of time.
What did you think of it? How did it make you feel?	Describe and reflect on thoughts and feelings with regards to the incident, event or issue at hand. Look at positive and negative thoughts and feelings for each situation.
How did you react?	Describe and reflect on behaviours, reactions or responses to the incident, event or issue. Look at positive and negative reactions for each situation.
Why did it happen?	Reflect on why you think this happened. Think about where the system broke down to allow a negative event to occur or how the system was supportive for positive events to occur.
What else could you have done?	Think about what other reactions, thoughts or feelings you could have taken or adopted in such a situation.
What will you do next time?	Develop a concrete action plan to reduce the probability of a negative action happening again and to build on a positive action for the future. Be specific, and build on your strengths and assets, or need for more information.
How will we communicate the lessons learnt from this investigation and any resulting changes in the organizational processes?	Use all experiences or actions as lessons learnt for the larger team.

10.7 Annex 5: Complaints/Filing Grievances Form [Download]

Case Managers, other staff of the agency, clients, and implementing partners or service providers have the right to bring complaints to the organization without fear of reprisal or being deprived of services.

INITIAL GRIEVANCE FORM

INSTRUCTIONS: Complete Section I and submit this form, along with any supporting materials, to the Case Manager. If the subject of this form involves the Case Manager, then the form should be submitted to the Case Supervisor. The person receiving the completed form must then complete Section II after relevant investigation or clarification, within 15 working days, unless otherwise stated.

Section I: (to be completed by the Complainant)

Name:

Tick as appropriate:

Client Case Manager Service provider Other Staff of SUKA

Case Number (if relevant):

Telephone no.:

Signature:

Date:

Describe the grievance clearly (attach additional sheets and supporting documentation as appropriate):

Section II: (to be completed by the Case Manager/Supervisor)

Name:

Title/Designation:

Telephone no.:

Date Received:

Signature:

Written explanation or resolution of response (attach additional sheets and supporting documentation as appropriate):

GRIEVANCE REVIEW FORM

INSTRUCTIONS: Complete Section I and submit it to the Case Supervisor. The Case Supervisor will review the grievance within 15 days unless otherwise stated and provide a record of the review in Section II.

Section I: (to be completed by the Complainant)

I have reviewed the Case Supervisor’s response to my Initial Grievance Form, dated .

I, (insert name), do not believe that the response to my grievance was satisfactory and request a review. Reasons for this are provided below.

Signature:

Case Number (if relevant):

Date:

Describe why the response is unsatisfactory:

Section II: (to be completed by the Case Supervisor)

Name:

Title/Designation:

Request for review received on:

Outcome of review and follow up action:

Date of Response:

Signature:

10.8 Annex 6: Do’s and Don’ts of Child Friendly Interviewing [Download]

This is a short guide for working with, and interviewing children, developed by the United States Conference of Catholic Bishops’ Migration and Refugee Services. The list is not exhaustive but provides a useful guide for Case Managers. This text is taken from materials shared during a webinar by Bridging Refugee Youth and Children’s Services (BRYCS) on 4 February 2016.

DO’S:

• DO use child-friendly age-appropriate language.

• DO be friendly and welcoming. Smile! Put the child at ease with your body language and demeanour.

• DO arrange seating so that you can face and speak directly to the child. Ensure that you are eye-level with the child (and not standing over him or her).

• DO clearly introduce who you are to both the caregiver and the child. Explain the purpose of the interview and what the child and caregiver can expect.

• DO let the child know that he or she is free to take a break for water, to use the restroom, or to “take a breather” at any point in the interview.

• DO ask easy questions to start off to help build the child’s confidence and comfort level.

• DO be creative with the interview. Use child-friendly activities. DO allow children to give free-narrative responses; patiently take notes of any follow up questions you have without interrupting the child. Start with broad questions, followed by more specific questions.

• DO go off-script. Although you may be using a checklist or form to direct the interview, the conversation will feel less stilted if you follow the flow of the conversation in an informal manner. At the end, look through your checklist to make sure you have not forgotten any important information.

• DO lead the child through the conversation so that he or she can easily follow the conversation. It is best NOT to jump from question to question without introducing new topics.

• DO observe the child carefully during the interview. Look for signs of distress and take appropriate action.

• DO take time in the conversation to summarize what has been discussed. Repeating back to the child what you have understood lets the child feel that his or her voice is being heard, and gives him/her an opportunity to correct any misunderstandings.

• DO take a deep breath to help handle any strong feelings and decide to process what you are feeling after the interview.

DON’TS:

• DON’T conduct interviews in non-confidential spaces or in places that are uncomfortable.

• DON’T act like a private investigator or intimidate the child with your way of questioning.

• DON’T cross-examine the child or assume the child is lying if the story changes.

• DON’T make assumptions about what children are thinking or feeling.

• DON’T show any frustration or scepticism during the interview.

• DON’T impose ideas or solutions or force a child to give information.

• DON’T interrupt a child who is in free narrative or answering a question, even if the information is not what you were expecting.

• DON’T fill silences which you find uncomfortable. Listen to the child carefully.

• DON’T ignore signs of distress, such as bruises, not talking, or uncontrollable crying. As a mandated reporter, it is your job and obligation under law to report suspected child maltreatment.

• DON’T use closed questions that allow the child only to answer “Yes” or “No”. (“Do you play soccer after school?” or “Do you love your aunt?”). Instead ask open-ended questions. (“What sports do you play after school?” or “What activities do you and your aunt do together?”).

• DON’T ask two questions in one.

• DON’T further distress the child. DON’T leave the child in the middle of telling a traumatic story to go do something else.

• DON’T forget to balance your time and resources, which could force you to have to cut off an interview. DO leave time for children to ask questions or provide additional comments.

• DON’T ignore the questions that children ask you.

• DON’T make false promises.

10.9 Annex 7: Guide to Working with Interpreters [Download]

Pre interview Preparation (particularly with new interpreters and prior to intake)

• Make arrangements to book an interpreter and ensure that the interpreter is of the same gender as the child so that the child feels comfortable to share. Identify if there is any existing relationship between the child and interpreter, which may lead to a conflicting situation.

• Where possible, have a pre-session discussion with the interpreter about any cultural factors that may affect the session, but remember that interpreters should not be considered as cultural experts.

• Brief the interpreter on the overall aim of the session, and services that are provided by the organization. Review the content of the session, especially sensitive topics (e.g., mental health status or sexual conduct). This allows the interpreter time to frame the proper questions, clarify terminology, or express discomfort questioning certain topics.

• Clarify the role of the interpreter. You should explain that the interpreter is to function as a voice to repeat the questions to the client and responses from the client without giving additional information, paraphrasing, or polishing the information with professional terminology or own interpretation.

• Explain the need for precise interpretation. The interpreter should repeat the questions and responses to maintain the same meaning, tone, and register as the original message. Nothing should be omitted, and nothing should be added, unless it is only to explain a word or phrase that the person does not understand.

• Explain that the interpreter may ask for clarification of information at any time, and may encourage the client to ask questions. If the session needs to be interrupted to allow for clarification, this should be conveyed to all, so everyone is kept aware of the discussion.

• Explain and emphasize the importance of confidentiality, as most interpreters are refugees themselves and are part of the same community.

• Inform the interpreter of any materials/forms that will need to be translated verbally, where necessary.

Preparing for the Session

• Sit facing the client. Look at the client and be aware of the body language. Avoid looking at the interpreter unless you are directly addressing him/her.

• Ask the interpreter to sit near you, whilst you directly face the client. Alternatively, the interpreter sits beside you with both of you facing the client at an angle so that the eye line is in the same direction for the client.

• Remember to speak directly to the client as you would without an interpreter.

• Always use the first person e.g., “how are you feeling?” and not, (to the interpreter) “ask her how she is feeling”.

• Do not try to save time by asking the interpreter to summarise the responses.

• Be aware that it may take more words to interpret to convey the message.

• Do not let the interpreter’s presence change your role in the session. The interpreter should not conduct the session as it is not his/her role.

Introduction (see intake brief)

• Follow conventions of etiquette to show respect (e.g., stand up when the person enters, shake hands if they initiate it, use titles such as Mr. and Mrs.)

• Introduce yourself and the interpreter. Alternatively, the interpreter may introduce himself/herself.

• Make sure that the client knows you are conducting the session and understands the interpreter’s role.

• Stress that both you and the interpreter are bound by a code of ethics to maintain the confidentiality of the session.

• Explain the purpose of the session and how it will be conducted. Allow the client to ask questions and raise any concerns they may have.

Conducting the Interview

• Speak a little more slowly than usual, and in your normal speaking tone. Speaking louder does not help. Pause after two sentences to allow the interpreter to relay the message.

• Use plain English where possible. Avoid complex terminology and acronyms. Summarise periodically when complex issues are involved.

• Give the interpreter enough time to process your information and to convey it to the client. Also allow the interpreter to complete a translation before jumping in with more information or questions.

• If the client does not understand, it is your responsibility (not the interpreter’s) to explain in simpler terms.

• Seek the client’s permission if you need to obtain cultural information from the interpreter, if it is required. However, avoid long discussions with the interpreter. If you need to talk to the interpreter directly, then the interpreter should explain to the person about the nature of the conversation.

• Speak directly to the client and not the interpreter. Address questions to the person as “you” rather than to the interpreter as “he” or “she”.

• Use short, simple sentences with fewer than sixteen basic words and ask one question at a time. Use active words rather than the passive voice (e.g. “I will ask you questions about your family” rather than “You will be asked questions about your family”).

• Avoid metaphors (e.g. like a maze), colloquialisms (e.g. pull yourself up by your bootstraps), and idioms (e.g. kick the bucket) because such phrases are unlikely to have equivalents in another language.

• Avoid the subjunctive mood (e.g. verbs with could or would) because not all languages have a subjunctive mood. Use specific rather than general terms (e.g. daily rather than frequent).

• Avoid medical terminology unless the interpreter and the person receiving the health service are familiar with the equivalent term.

• When speaking or listening, mainly watch the person rather than the interpreter so that non-verbal messages can be observed. This can be accomplished by having the interpreter sit next to you and across from the person being interviewed.

• Be aware of non-verbal communication and verify its meaning in the person’s culture. Be aware of your own non-verbal communication (e.g. norms for direct eye contact, touch and proximity often differ among cultures). Be culturally sensitive and knowledgeable, but do not stereotype. The best source of information on cultural appropriateness is the person being interviewed.

• Do not make comments that you do not want interpreted. The person may understand more than you realise.

After the Interview

• Check that the client has understood the key messages in your session. Ask if they have any questions.

• If the client requires another appointment, make those arrangements while the interpreter is still there.

• Thank your client and explain that you may need to have a post-appointment discussion with the interpreter. Formally end the session.

• Debrief with the interpreter if the session was emotionally taxing and clarify any questions you have arising from the session.

• Reimburse the interpreter accordingly – an hourly rate plus transport costs, where necessary.

• For continuity, ensure that you use the same interpreter for follow up interviews/sessions.

10.10 Annex 8a: Government/UN Agency Referral Form [Download]

This form is to be used only for referrals of UASC who have declared themselves as being below 18 years of age. Information is to be filled in as comprehensively as possible on this form. All information must be kept confidential. Please ensure the UASC has consented to the sharing of information in this referral. Please email completed forms to uasc@sukasociety,org.
DEMOGRAPHIC DETAILS OF THE CHILD (including contact information, child’s history and background information)
Name of the child (including all aliases):
Date of birth or age:
Ethnicity and country of origin:
Gender:
UNHCR no. or other documentation no.:
Current status of UNHCR or any migration processing:
Current address:
Telephone no.:
Languages spoken:
CAREGIVER(S) INFORMATION AND CONTACT DETAILS
Name:
Address:
Telephone no.:
UNHCR no. or other documentation no.:
Languages spoken:
Relationship with the child:
Name:
Address:
Telephone no.:
UNHCR no. or other documentation no.:
Languages spoken:
Relationship with the child:
Background information on caregiver(s), if any:
CHILD’S HISTORY OR BACKGROUND (note any particular vulnerabilities, such as victim of trafficking, exploitation, abuse, or trauma)
CHILD’S CURRENT CAREGIVER AND LIVING ARRANGEMENTS
E.g., Who does the child stay with? Is the child paying rent or any monies to the household? Does the child feel comfortable staying there?
CHILD SAFETY - Is the child safe in current caregiver arrangement?
Yes, the child is safe.	No, the child is not safe.
Any other comments:	The following safety risks have been identified: Child’s caregivers cannot or will not protect/provide for the child. Child has no caregiver and is living on his/her own. Child has experienced abuse and the perpetrator lives with the child or can easily access the child at home. Other reasons (please identify): ______________________________
CHILD HEALTH NEEDS - Does the child require a health referral for treatment?
Does the child have any diagnosed illness or ongoing health condition?
Yes (please specify below)	No Not known
Diagnosed illness: Current treatment (treatment location and type):
If not known, does the child require a health referral?	No, a referral is not needed because:
CHILD PSYCHOSOCIAL NEEDS – What is the child’s current emotional state and level of functioning?
Report of child’s emotional state or current behaviour: Emotional trauma from detention Stopped going to school Stopped leaving the house Stopped playing with friends Feels sad most of the time Exhibits sleeping or eating changes Other major changes or difficulties reported:	Describe the child’s emotional state (describe expressed or observed emotional state of the child):
Is the child receiving psychosocial support or counselling? Yes No Not known Not needed
If yes, please specify where and what kind of support:	What is the caregiver’s understanding of the child’s current functioning? Explain if known.
WELFARE NEEDS – Is the child’s basic welfare needs being met?
Does the child have a safe place to stay? Yes No Not known Does the child feel safe or comfortable staying there? Yes No Not known Is the child required to pay rent? Yes No Not known If yes, is the child able to pay rent on his/her own? Yes No Not known N/A Does the child have his/her own room? Yes No Not known Does the child have bedding? Yes No Not known Does the child’s room have adequate ventilation? Yes No Not known	Is there adequate sanitation in the home? Yes No Not known Is the overall housing environment clean – no water stagnation, rodents? Yes No Not known Is the child’s house clean and not overcrowded? Yes No Not known Does the child have adequate nutritious food to eat on a daily basis? Yes No Not known Does the child have access to other basic needs such as sanitation items, clothes, shoes? Yes No Not known
Any other relevant basic needs identified:
SPECIFIC TRAUMA OR EXPLOITATION ASSESSMENT- What is the child’s current emotional state and level of functioning?
Has the child been arrested and detained? Yes No If yes, for how long was the child in detention: _________________________________________	Any related experience during detention that the child has shared:
Has the child experienced any specific incidences of violence in his/her home country or in Malaysia?	If yes, please briefly describe incidences:
Yes No
REFERRAL AGENCY INFORMATION
Referrer name:	Agency:
Designation/Title:	Case ref. no. (if any):
Email:	Telephone no.:
Date of referral:
Has the client provided necessary informed consent to the sharing of information for this referral? YES NO
Has there been any intervention carried out by your agency? YES NO If yes, please list:
Please list any safety concerns to note:

Yes, a health referral is needed because:

Child complains of physical pain and injury.

Child has not received any health treatment since entering the country or since being released from detention.

Other reasons (please explain): _______________________________________________________

Services already received from another agency.

Service not applicable.

Other reasons (please explain):

_______________________________________________________

For Office Use

Date received:

Received by:

Follow up action:

• Intake interview scheduled – Date: ___________________________________________________

• Referral rejected – Reasons: __________________________________________________________

• Referral to another agency – Agency name: _________________________________________

• Emergency intervention – Specify: ___________________________________________________

• Others: _______________________________________________________________________________

10.11 Annex 8b: NGO/CBO Referral Form [Download]

NGO/CBO REFERRAL FORM

This form is to be used only for referrals of UASC who have declared themselves as being below 18 years of age. Information is to be filled in as comprehensively as possible on this form. All information must be kept confidential. Please ensure the UASC has consented to the sharing of information in this referral. Please email completed forms to uasc@sukasociety.org.

REFERRAL AGENCY INFORMATION
Referrer name:	Agency:
Designation or title:	Case ref. no. (if any):
Email:	Telephone no.:
Date of first interview/contact with UASC:
Has the client provided necessary informed consent to the sharing of information for this referral? YES NO
UASC/CLIENT PERSONAL BIODATA
Name (all aliases):	Sex: MALE FEMALE
Date of birth, year of birth or an approximate age:	Nationality:
Ethnicity:	Languages spoken: (please underline preferred language of communication if more than one)
Please list all legal documents that the client possesses (passport, UNHCR appointment card, UNHCR card, any other national identity documents):
Legal status:	UNHCR/Passport/Other documentation no.:
General location/place of residence (exact address not needed):
Telephone no.:
CAREGIVER INFORMATION FOR SEPARATED MINORS (if known)
Name:	Relationship with the child:
Ethnicity:	Nationality:
Languages spoken: (please underline preferred language of communication if more than one)	UNHCR/Passport/Community card/Other documentation no.:
General location/place of current residence:	Telephone no.:
UASC BACKGROUND INFORMATION
Please list below in detail any specific vulnerabilities identified by your agency, including (but not limited) to the following:
OTHER CASE INFORMATION (if known)
Has an age assessment been conducted? YES NO	If yes, please specify by whom:
Has the client been referred to UNHCR? YES NO	If yes, please specify by whom and reasons for referral:
Has your agency conducted any intervention for the client? YES NO	If yes, please specify intervention conducted:

• vulnerabilities related to serious physical and/or mental health concerns.

• sexual, physical, mental abuse/violence in Malaysia and/or from country of origin, or en route to Malaysia.

• incidences of trafficking en route or currently in Malaysia.

• previous and/or current incidences of arrest and detention in Malaysia.

• current living conditions and/or caregiver arrangements that are unsafe or where the child is at risk of abuse and exploitation.

• child labour in exploitative and unsafe conditions.

REASONS FOR REFERRAL
Please specify reasons for referral to SUKA Society:
Date:

For Office Use

Date received:

Received by:

Follow up action:

• Intake interview scheduled – Date: ___________________________________________________

• Referral rejected – Reasons: __________________________________________________________

• Referral to another agency – Agency name: _________________________________________

• Emergency intervention – Specify: ___________________________________________________

• Others: _______________________________________________________________________________

10.12 Annex 9a: Programme Screening Tool [Download]

Cases referred by NGOs, CBOs, UNHCR, and self referred cases will be screened to assess if the case is within program requirements. Screening is also carried out to assess any present safety issues for the UASC. All information must be stored in a confidential manner.

REFERRAL INFO
Client Name (all aliases):	Sex: FEMALE MALE
Date of birth, year of birth or an approximate age:	Country of origin:
General Location: (exact address preferred)	Contact Number:
Referred by:	Referred date:
SCREENING CHECK
Is the child below 18yo: Yes No	Is the child in the Klang Valley: Yes No
Is the child unaccompanied: Yes No	Is the child separated (if yes describe relative): Yes: ____________________________ No
Does the child have any formal caregiver Yes No If yes, please describe who it is:
Is the child safe? Yes No	Who is the child staying with: (incl info on who else is in the house)
Describe place of residence and living arrangements: (incl info whether the child has his/her own room)
Does the child have any documentation: Yes No If yes, please describe documentation:
Any known vulnerabilities: Ongoing or previous SGBV, SVT, Trafficking, and any other form of exploitation Medical concerns (Physical health) Mental Health concerns Detention, repeated arrest or risk of deportation
Any other comments:
SCREENING DECISION
Within program scope: Yes No	Priority assessment: Emergency (intervention before scheduling) Highest Urgent (within 3 days) Urgent (within 7 days) Normal (within 3 weeks)
Scheduled for Intake by (date):	Assigned Interviewer (name):
Assigned Case Ref No:	Interpreter needed: Yes No
SCREENING ASSESSMENT DONE BY:
Name:	Position:
Signature:	Date of assessment:

For Office Use:

Screening decision communicated to interviewer - Date:

Screening decision communicated to referral agency – Date:

Screening decision communicated to client – Date:

10.13 Annex 9b: UASC Arrest and Detention Screening Tool [Download]

CASE NUMBER: ___________________________________

UASC understands purpose of screening	YES NO
UASC consents to screening process	YES NO
UASC consents to tracing activities where needed	YES NO
UASC consents to storing and sharing of information with other organizations involved in the screening and/or release process	YES NO
PERSONAL BIODATA
Name (all aliases):	Sex: MALE FEMALE
Date of birth, year of birth or an approximate age:	Place of birth:
Country of origin:	Ethnicity:
Religion:	Languages spoken:
Legal status:	Documents the UASC possesses, if any:
Date of arrival in Malaysia:	Reason for entry into Malaysia:
Previous address:	Previous telephone no.:
DETENTION INFORMATION
Current location:	Place of arrest:
Date of placement in current location:	Date of arrest:
Charges:	Status of processing:
Actions undertaken by the authorities for case resolution (e.g., contacting embassies, UNHCR, etc.):
NEXT OF KIN INFORMATION
Name of father:
Legal status (if in Malaysia):	Telephone no.:
Current location and other relevant details (e.g. body number if detained):
Name of mother:
Legal status (if in Malaysia):	Telephone no.:
Current location and other relevant details (e.g. body number if detained):
Name of sibling(s) in Malaysia ( please list all):
Legal status:	Telephone no. of each person listed:
Current location and other relevant details (e.g. body number if detained):
Name of sibling(s) outside of Malaysia:
Current location and other relevant details (e.g. body number if detained):	Telephone no. of each person listed:
Name of extended relatives in Malaysia (please list all):
Legal status:	Relationship to child:
Current location and other relevant details (e.g. body number if detained):	Telephone no. of each person listed:
Name of primary caregiver in Malaysia:
Legal status:	Telephone no.:
Current location and other relevant details (e.g. body number if detained):
VULNERABILITIES/PROTECTION CONCERNS
Protection concerns from country of origin (such as trafficking en route, SGBV, SVT)	YES NO
Remarks/Details:
Medical (Physical health) concerns	YES NO
Please list medical complaints/disabilities (if any):
List any previous diagnosed medical concerns:
Medications (if any):
Medical (Mental health) concerns	YES NO
Please list medical complaints/disabilities (if any):
List any previous diagnosed mental health concerns:
Medications (if any):
Any other vulnerabilities or concerns	YES NO
Remarks/Details:
SCREENING CONDUCTED BY
Name:	Position:
Organization:	Date of documentation:
Signature:
SCREENING ASSESSED BY
Name:	Position:
Organization:	Date of assessment:
Signature:
OUTCOME OF SCREENING

10.14 Annex 10: Introductory Brief for Case Managers for the Intake Interview [Download]

• Hi, thank you for meeting me/us today. My name is ______ and I am a volunteer Case Manager. This is ____ and he/she is also a Case Manager [if there is another person there].

• I/We work with the organization called SUKA Society. SUKA Society is a non-governmental organization like MSRI/ Asylum Access/SSC/ [insert other NGO names where relevant].

• I/We work mainly with people below the age of 18, who are here without their parents or close family members.

• I/We provide case management for such minors to look into their needs.

• I/We are not UNHCR/UNHCR officers.

• [Ask the interpreter to introduce himself/herself] or say this is ____ and he/she will be your interpreter for today.

• The interpreter’s role is to interpret exactly everything you say.

• It is important that you speak in short sentences so that your interpreter can tell me/us what you said accurately and completely.

• The interpreter will not be able to answer any of your questions directly. You should direct all your questions to me.

• Your interpreter has signed an agreement to ensure confidentiality. Everything you share with us will be kept confidential by the interpreter.

• The interpreter will also speak in first person – using words such as “I said” – as he/she will be interpreting exactly what you said.

• The purpose of the interview today is to understand you a little bit better.

• I/We will ask you some questions about yourself.

• Specifically, I/we will ask you questions about your situation in Malaysia – including where you are living, your health, education, and employment. I/We will also take down some biodata (such as your name, age, etc.). I/We will also ask you about your family and what happened to you in the country you came from. I/We will also ask you about your journey to Malaysia and any trauma or difficulties you have faced in Malaysia or in the country you came from. Finally, I/we will ask you questions about your interests and goals.

• I/We want you be as honest as possible with me/us today.

• If you are not honest, SUKA Society will not be able to provide the best assistance for you.

• Once again, everything you say will be kept confidential.

• I/We will not share the information you give with anyone without your consent.

• If you feel uncomfortable in answering any question, let me/us know and I/we will move on to another question.

• The interview will take about 1 ½ hours.

• If at any time you feel tired and want to stop, let me/us know and I/we will continue the interview on another day.

• I will be [*typing on my computer] or [writing notes]* so that I can remember everything you have said. Is this ok?

• By answering questions today, it does not mean SUKA Society will take on your case or provide any support.

• Once we have your information, we will discuss it in the organization and make a decision about whether we are able to take you on as a client.

• Do you have any questions? [Answer them if yes]. You may ask me/us any questions during the interview if needed.

• Are you ready to proceed with the interview? If yes, we will begin with some biodata questions…

10.15 Annex 11: Client Needs and Risks Intake Form [Download]

Demographic details of the child (including contact information, child’s history, and other background information)	[insert photo* *of the child]
Name of the child (include aliases):
Date of birth or year of birth: (include type of document with the DOB)
Gender:
UNHCR or other legal identity documentation: (include type of card, card number, reference number, appointment dates, or expiry date)
NGO or Community card no.:
Address:
Telephone no.:
Nationality:
Ethnicity:
Country of origin and place of birth: (village, township, district/state, country)
Religion:
Languages spoken:
Date of arrival in current country:
For office use:
Case reference no.:
Case Manager/Interviewer’s name:
Date, time and place of interview:
Referring agency: (name of agency and/or individual)
Reasons for referral:

Note: Some of these areas of assessments below may not apply. Please use discretion. These questions are merely a guide and Case Managers should adapt questions according to the situation.

Area of assessment	Guiding/Probing questions
Daily functioning or welfare needs	Describe where you live
Notes/Responses
Family functioning or caregiver arrangements	Caregiver relationship
Notes/Responses
Asylum claim and entry into Malaysia	Parents information
Notes/Responses
Documentation	Legal documentation
Notes/Responses
Health needs	Do you have any current health issues? Please describe – probe further where necessary.
Notes/Responses
Social networks and support	Do you have any friends in Malaysia? Who are they? – Names? Ages?
Notes/Responses
Education and employment	Education:
Notes/Responses
Background experiences or traumatic events Extent of exposure to violence and displacement	Have you been arrested or detained by immigration in Malaysia?
Notes/Responses
Psychological symptoms seriously interfering with daily life	Anxiety
Notes/Responses
Interests and goals	What do you like to do? What are enjoyable activities, hobbies, interests?
Notes/Responses

• Type of accommodation – house, apartment, hostel - and the location.

• Describe the house/apartment – Which floor? How many rooms? Are there bathrooms, a kitchen, etc.? How many people per room?

• How many people stay with you? Who are they? What are their names? Are they registered/documented? What are their ages and gender?

• Describe your room - What is in your room? (Bed, table, cupboard, fan, windows, etc.) How big is your room roughly?

• Describe the surroundings – Is there security? Is it clean? Is it safe? Is there a park? Who stays in the building generally? Are there police nearby?

• How do you feel about the place where you are currently staying?

• Do you feel safe?

• Do you feel comfortable?

• What makes you feel unsafe/uncomfortable?

• Describe your daily activities

• What do you do every day?

• What time do you wake up?

• What time do you go to bed, etc.?

• Describe your meals and dietary needs

• How many meals do you typically have? - Describe what you eat for each meal.

• Do you have any food allergies?

• What do you like to eat/not like to eat?

• Do you cook? What can you cook?

• Describe your financial situation

• How do you provide for yourself financially?

• How much is your rental (inclusive of utilities)? How do you pay rent?

• How do you pay for your meals/food?

• How much money did you bring with you from your home country?

• How much money do you have left? What have you spent it on?

• Who takes care of you? Is there anyone who cares for you in the home?

• Describe your relationship with your caregiver if they are not your
  parents.

• How do you feel about the person(s) who takes care of you?

• Family relationships

• Do you have any family members (siblings, uncles, aunts, cousins) in Malaysia? – Who are they? Where are they? Are you in contact with them? Are they registered with UNHCR? What support do they provide you?

• Do you have any other distant relatives here? – Who are they? Where are they? Are you in contact with them? Are they registered with UNHCR? What support do they provide you?

• Do you know anyone else in Malaysia from your village or hometown? – Who are they? Where are they? Are you in contact with them? Are they registered with UNHCR? What support do they provide you?

• Do you have any relatives/family members in countries other than
  Malaysia and in your country of origin? – Who are they? Where are they? Are you in contact with them? What support do they provide you?

Obtain telephone contact numbers of persons where possible or relevant.

• Do you know who your parents are and where your parents are currently residing? - Obtain parents’ names, ages and legal status.

• If yes, where? When was the last time you contacted them? Do you have a working telephone number to contact them?

• If no, what happened to them? (ask questions where relevant but without traumatising the child)

• Siblings information

• Do you have any siblings? - Obtain siblings names, ages and legal status.

• If yes, please elaborate – How many? Their ages? Their gender?

• Where are they now? (ask questions where relevant but without traumatising the child)

• Entry into Malaysia

• When did you enter Malaysia? – Date? (check passport to verify accuracy, if possible)

• How did you enter Malaysia? Describe your journey – including all transit points.

• With whom did you enter the country?

• When you landed at the airport, what happened?

Note any trauma/violence experienced and probe further only where necessary without traumatising the child.

• Place of stay prior to departure

• Where were you staying before you left for Malaysia?

• Is this the same place where you were born? How long were you staying in this place?

• How old were you when you left this place?

• Asylum claim or reasons for migration

• In as much detail as you feel comfortable sharing, why did you leave this place to come to Malaysia?

Note any trauma/violence experienced and probe further only where necessary without traumatising the child.

• What legal documentation do you have? For each, please describe what they are.

• Do you have this documentation with you now?

• Are these documents genuine/real?

• Who prepared the documents?

• What documentation did you use to enter the country?

• Do your caregiver/parents have any form of legal documentation? Please describe what they are.

• Have you been interviewed/registered by UNHCR? What happened during the interview, what documents did you obtain?

• If you haven’t been registered by UNHCR, have you tried approaching UNHCR? What happened during these times?

• Have you tried approaching any other organization to obtain your documents in Malaysia? What happened during these instances?

• Do you know if you have any pre-existing illness?
  • If yes, what is it? – details, and reports where possible.

• Have you seen a doctor or been to the hospital since entering Malaysia? What happened during this visit to the doctor?

• Have you seen a doctor or been to a hospital in your home country? What happened during this visit to the doctor?

• Are you on any medication? Are you supposed to be on any medication?

• Do you have any pain/discomfort currently? – If yes, where, what kind?

• Do you have a cough, fever? – If yes, how long?

• Do you have issues with your sight, hearing, and teeth?

• Have you had any fall in your country of origin or in Malaysia? – if yes, probe further.

• Do you have any skin issues?

• Any known disability? – if not visible.

• What do you do with these friends? How often do you meet them?

• What about community members? Do you go to your community events?

• Where is your place of worship? How often do you go?

• Did you attend school in your country of origin?

• If yes, what grade did you complete?

• If no, why not?

• Are you currently attending school?

• If yes, please describe your school.

• Do you like going to school? What is the best part about going to
  school? And what is the worst part?

• If no, why not?

• If no, would you like to go to school?

Employment:

• If you are not in school, are you working? If yes:

• What work do you do?

• How long do you work?

• Do you get paid? If yes, how much?

• Do you like your work?

• What are some good things about your work?

• What are some not so good things about your work?

• Do you have any problems with your boss, co-workers? Please describe.

• Do they treat you well?

• Do you like working? Do you want to continue working?

• Did you work in your country of origin? If yes, see questions about work above and repeat.

• Are you keen to attend school or work here in Malaysia?

• Are you expected to send money home to your family? How much do you send a month?

• If yes, please describe your experience.

• How long? Where were you detained? For what reasons? How were you released?

• Have you had encounters with the police in Malaysia?

• If yes, please describe instances – when, where, what happened, how were you released?

• Have you experienced any violence during your journey to reach Malaysia? (physical, sexual, verbal, or emotional)

• During your stay here, has anybody treated you badly, hurt you or made you feel uncomfortable?

• If yes, who are these persons?

• What did they do to you?

For minors who are less verbose – yes or no answers are encouraged
without details. For example: during your journey to Malaysia did anyone
1. Physically abuse you? 2. Sexually abuse you? 3. Verbally abuse you?
4. Emotionally abuse you?

• Do you worry all the time? (may be expressed as head hurting)

• What do you worry about?

• Are you able to sleep at night? How much sleep do you get?

• Are you able to concentrate at work/in school? Do you have any
  difficulties remembering things?

• Depression

• How do you feel right now?

• How do you feel about yourself?

• How is your appetite? How is your energy level?

• Do you feel like hurting yourself sometimes? Have you hurt yourself
  in the past?

• Anger

• Do you find yourself getting angry very easily? Describe instances.

• What makes you angry?

• What do you do when you are angry?

• Trauma

• Do you have nightmares or flashbacks of a particularly traumatic event? If yes, please describe.

• Have you gone for, or are you going for counselling/seeking mental health treatment?

• If yes, where?

• If no, would you like to speak to a professional? Explain what counselling is in very simple terms.

• Are you currently using any substances?

• Do you smoke? Drink alcohol? Use drugs?

• Have you used any substances?

• Have you smoked, drunk alcohol or used drugs in your country of origin?

• What are your immediate and longer-term goals?

• What do you hope for in the future?

Has any other organization interviewed you like this before?

⎕Yes ⎕ No

Are you receiving/have you received any support from any other organization?

⎕Yes ⎕ No

Note down if the client is receiving services from any other service provider. Please list service providers and type of services.

Need area	Service provider (Organization name)	Type of service
Welfare support
Physical health
Mental health
Education
Employment
Legal status or documentation
Housing
Other(s)
Other(s)

10.16 Annex 12: Heightened Risk Rating Form [Download]

A rating assessment is to be carried out following the completion of the Client Needs and Risks Intake Form. Information gathered from the form may be evaluated using the following risk ratings. Please note that the accuracy of the rating is based merely on the information gathered in the intake interview and therefore, in some instances, a home visit is necessary for an accurate assessment. Please also note that the items per rating are related to the scope of SUKA Society’s Community Placement and Case Management Programme and therefore should not be taken as an exclusive list for all organizations. For Case Managers: please fill in specific details related to the case in the remarks section when high/moderate risk is identified. Print a copy for the file

Case ref. no.:	Date of assessment:
Full intake interview conducted: Yes No	Home visit conducted: Yes No
CRITERIA	X	REMARKS
Item 1
HR	Unaccompanied child living in the community
MR	Separated child below the age of 14 living in the community
LR	Separated child above the age of 15 living in the community
Item 2
HR	Single female child
MR	Single male child or female separated child
LR	Male separated child
Item 3
HR	Has no legal documentation – at risk of arrest or detention
MR	Has some legal documentation but still at risk of arrest or detention
LR	Has legal documentation and no clear risk of arrest or detention
Item 4
HR	Unsafe living arrangements – child in present danger17
MR	Unsafe living arrangements – child in imminent danger18
LR	Safe living arrangements or caregiver arrangements
Item 5
HR	Trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
MR	At risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
LR	Not at risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
Item 6
HR	Engaging in survival sex
MR	At risk of engaging in survival sex
LR	Not at risk of engaging in survival sex
Item 7
HR	Forced labour and unsafe work conditions
MR	Voluntarily working but under moderately safe work conditions
LR	Not working or working under safe conditions
Item 8
HR	Prior incidences of actual sexual and gender based violence or torture by State or non-State actors
MR	Prior incidences of being at risk or receiving threats of sexual and gender based violence or torture by State or non-State actors
LR	No prior incidences of actual sexual and gender based violence or torture by State or non-State actors
Item 9
HR	Clear risk or threat of deportation or refoulement
MR	Moderate threat of deportation or refoulement
LR	No threat of deportation or refoulement
Item 10
HR	Severe psychological concerns affecting daily functioning, and significant health concerns (excluding physical and mental disabilities) requiring immediate or emergency intervention
MR	Moderate psychological or physical health concerns affecting daily functioning and requiring urgent intervention
LR	No psychological or physical health concerns requiring intervention

Rating[^20]

[^20]: Interventions based on rating classification: A high risk
classification requires immediate intervention and quick admission into the
programme. This includes interventions particularly related to living
arrangements, to be conducted within **three days** following a risk
classification. A moderate risk classification requires urgent intervention
and admission into the programme pending available resources. This includes
intervention related to living arrangements, which can be conducted within
30 days following a risk classification. A low risk classification may only
require some minor interventions and, typically, the client will not be
admitted into the programme.

    **Number of X**

    **Final Rating**

High Risk (HR)		High Risk High to Moderate Risk Moderate Risk Moderate to Low Risk Low Risk
Moderate Risk (MR)
Low Risk (LR)
Remarks/Recommendations:

Sample Completed Heightened Risk Rating Form

A rating assessment is to be carried out following the completion of the Client Needs and Risks Intake Form. Information gathered from the form may be evaluated using the following risk ratings. Please note that the accuracy of the rating is based merely on the information gathered in the intake interview and therefore, in some instances, a home visit is necessary for an accurate assessment. Please also note that the items per rating are related to the scope of SUKA Society’s Community Placement and Case Management Programme and therefore should not be taken as an exclusive list for all organizations. For Case Managers: please fill in specific details related to the case in the remarks section when high/moderate risk is identified. Print a copy for the file

Case no.: 0001	Date of assessment: 01/01/01
Full intake interview conducted: Yes No	Home visit conducted: Yes No
CRITERIA	X	REMARKS
Item 1
HR	Unaccompanied child living in the community		e.g. 15 year old unaccompanied minor living in the community
MR	Separated child below the age of 14 living in the community
LR	Separated child above the age of 15 living in the community
Item 2
HR	Single female child		e.g. unaccompanied male child
MR	Single male child or female separated child
LR	Male separated child
Item 3
HR	Has no legal documentation – at risk of arrest or detention		e.g. passport with expired visa. No other documentation
MR	Has some legal documentation but still at risk of arrest or detention
LR	Has legal documentation and no clear risk of arrest or detention
Item 4
HR	Unsafe living arrangements – child in present danger		Housemates drink with reports of violent behaviour when drunk
MR	Unsafe living arrangements – child in imminent danger
LR	Safe living arrangements or caregiver arrangements
Item 5
HR	Trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)		At risk of labour/work exploitation from current work conditions and given age
MR	At risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
LR	Not at risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
Item 6
HR	Engaging in survival sex
MR	At risk of engaging in survival sex
LR	Not at risk of engaging in survival sex
Item 7
HR	Forced labour and unsafe work conditions		Working on a construction site. Job secured by an agent. Works to be able to pay rent and buy food. Hard labour work.
MR	Voluntarily working but under moderately safe work conditions
LR	Not working or working under safe conditions
Item 8
HR	Prior incidences of actual sexual and gender based violence or torture by State or non-State actors		SGBV from country of origin.
MR	Prior incidences of being at risk or receiving threats of sexual and gender based violence or torture by State or non-State actors
LR	No prior incidences of actual sexual and gender based violence or torture by State or non-State actors
Item 9
HR	Clear risk or threat of deportation or refoulement		Lack of documentation and current work condition = risk of arrest or detention = risk of deportation if arrested
MR	Moderate threat of deportation or refoulement
LR	No threat of deportation or refoulement
Item 10
HR	Severe psychological concerns affecting daily functioning, and significant health concerns (excluding physical and mental disabilities) requiring immediate or emergency intervention		Health concerns from work conditions Psychological concerns from SGBV trauma
MR	Moderate psychological or physical health concerns affecting daily functioning and requiring urgent intervention
LR	No psychological or physical health concerns requiring intervention

• Single male adult household

• Overcrowded – 10 persons

• Minor lives in the hall

Rating	Number of X	Final Rating:
High Risk (HR)	5	High Risk High to Moderate Risk Moderate Risk Moderate to Low Risk Low Risk
Moderate Risk (MR)	4
Low Risk (LR)	1
Remarks/Recommendations: Recommendation for full case management

Interventions based on rating classification:

• A high risk classification requires immediate intervention and quick admission into the programme. This includes interventions particularly related to living arrangements, to be conducted within three days following a risk classification.

• A moderate risk classification requires urgent intervention and admission into the programme pending available resources. This includes intervention related to living arrangements, which can be conducted within 30 days following a risk classification.

• A low risk classification may only require some minor interventions and, typically, the client will not be admitted into the programme.

HIGH RISK RATING[^21]

[^21]: Please note that although early marriage, early pregnancy and
physical disabilities are high risk rating items, these are beyond the scope
of SUKA’s programme and, as such, are not included in the rating process.

No.	Item
	Unaccompanied child living in the community
	Single female child
	Has no legal documentation – at risk of arrest or detention
	Unsafe living arrangements – child in present danger
	Trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
	Engaging in survival sex
	Forced labour and unsafe work conditions
	Prior incidences of actual sexual and gender based violence or torture by State or non-State actors
	Clear risk or threat of deportation or refoulement
	Severe psychological concerns affecting daily functioning, and significant health concerns (excluding physical and mental disabilities) requiring immediate or emergency intervention
MODERATE RISK RATING
No.	Item
	Separated child below the age of 14 living in the community
	Single male child or female separated child
	Has some legal documentation but still at risk of arrest or detention
	Unsafe living arrangements– child in imminent danger
	At risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
	At risk of engaging in survival sex
	Voluntarily working but under moderately safe work conditions
	Prior incidences of being at risk or receiving threats of sexual and gender based violence or torture by State or non-State actors
	Moderate threat of deportation or refoulement
	Moderate psychological or physical health concerns affecting daily functioning and requiring urgent intervention
LOW RISK RATING
No.	Item
	Separated child above the age of 15 living in the community
	Male separated child
	Has legal documentation and no clear risk of arrest or detention
	Safe living arrangements or caregiver arrangements
	Not at risk of being trafficked, abducted, kidnapped or harboured by means of threat or force for the purpose of exploitation (e.g., prostitution, other forms of sexual exploitation, slavery, work exploitation or the removal of organs)
	Not at risk of engaging in survival sex
	Not working or working under safe conditions
	No prior incidences of actual sexual and gender based violence or torture by State or non-State actors
	No threat of deportation or refoulement
	No psychological or physical health concerns requiring intervention

10.17 Annex 13: Programme Admission Form [Download]

Case Reference No.:

GOALS AGREED ON (to be filled during the Case Conference)

Status in the Programme: (tick where applicable) Case Management Intervention only	Date of decision:
Goals or interventions agreed on:	Required time of completion:

CASE REVIEWED (where applicable)

Current status in the Programme: (tick where applicable) Case Management Intervention only	Date of decision:
Goals or interventions agreed on:	Required time of completion:
Purpose of review:	Date of review:
New goals or interventions agreed on:	Required time of completion:

CASE SUMMARY AND RECOMMENDATIONS (to be completed by the Case Manager)

Case Ref. No.: Case Manager:	Date:
Full intake interview conducted: Yes No	Date:
Home visit conducted: Yes No	Date:

SUMMARY OF RISK ASSESSMENT (to be completed by the Case Manager)

Risk Rating Form completed:	Yes No
Risk rating assessment: (please tick) High Risk High Risk – Moderate Risk Moderate Risk Moderate Risk – Low Risk Low Risk	Remarks: (summarize key risks /protection concerns based on the risk rating form)

SUMMARY OF CASE (include information under these headings)

Biodata (age, nationality, ethnicity, and gender)

• Date of arrival in Malaysia

  • Current legal status (availability of documentation and type)

    • Housing or safety issues with housing

      • Family (presence of any extended family/current family – whereabouts, support, etc.)

      • Physical health (current and previous)

      • Mental health (current and previous)

      • Education

      • Employment

      • Arrest and detention

      • SGBV or SVT incidences

      • General asylum claim

      • Ties or support from CBOs, NGOs, or UNHCR

      • Skills and coping style

      • Any verification of information from third party sources

      • Any behavioural concerns

Interviewer/Case Manager observations:
Recommendations on status and goals or interventions to be carried out:

BUDGET ASSESSMENT (to be completed by the Case Manager)

Budget required and proposed amounts:

APPROVAL PROCESS (to be completed during the Case Conference)

Please fill in the section on the agreed goals at the top of this document and ensure that the Case Management Payment Schedule in Google drive is updated during the Case Conference for administrative/accounting purposes.

Case approval
Accurate assessment of risk criteria? Yes No	Accurate assessment of recommendations? Yes No
Adequate Case Manager capacity to carry out interventions or case management services? Yes No	Accurate budget submission? Yes No
Approved for admission to Community Placement and Case Management Programme? Yes No Please fill in the section on the agreed goals on the first page of this document
Approved by: Name: Signature:
Date:
Name of assigned Case Manager:

10.18 Annex 14: Child Trauma Screening Questionnaire [Download]

Please indicate whether any of these things have happened to you since the event

No	Item	Response (Mark √)
	Do you have a lot of thoughts or memories about the event that you do not want to have?	Yes	No
	Do you have bad dreams about the event?	Yes	No
	Do you feel or act as if the event is about to happen again?	Yes	No
	Do you have bodily reactions (such as a fast-beating heart, stomach churning, sweating and feeling dizzy) when reminded of the event?	Yes	No
	Do you have trouble falling or staying asleep?	Yes	No
	Do you feel grumpy or lose your temper?	Yes	No
	Do you feel upset by reminders of the event?	Yes	No
	Do you have a hard time paying attention?	Yes	No
	Are you on the “look-out” for possible dangerous things that might happen to yourself and others?	Yes	No
	When things happen by surprise or all of a sudden, does it make you “jump”?	Yes	No

Scoring: Respond to each question with either a ‘yes’ (scored 1) or a ‘no’ (scored 0) indicating whether or not you have experienced the symptom since the event. Answering ‘yes’ to 5 or more questions is identified as being at high risk of developing PTSD.

Reference: Kenardy, J., Spence, S., and Macleod, A. (2006). Screening for risk of Persistent Posttraumatic Morbidity in children following traumatic injury. Paediatrics. 118, 1002-1009.

“The CTSQ has also been used as a concurrent screening tool with children and has demonstrated excellent case-finding properties. The findings from this research can be found in the following publication:

Charuvastr, A., Goldfarb, E., Petkova E. and Cloitre, M. (2010). Implementation of a Screen and Treat Programme for Child Posttraumatic Stress Disorder in a School Setting After a School Suicide. Journal of Traumatic Stress, Vol. 23, No. 4, pp. 500-503.”

** Pending permission to use from Justin Kenardy, PhD Centre of National Research on Disability and Rehabilitation Medicine, Edith Cavell Building, Royal Brisbane and Women’s Hospital, University of Queensland, Herston QLD 4029, Australia. Or email: j.kenardy@uq.edu.au.

10.19 Annex 15: Client Programme Consent Form [Download]

Please ensure that the following consent form is translated and printed in a language that the client/parent understands. Please also ensure that the form is read out and clearly explained to the client.

SUKA Society is an organization that works with persons below the age of 18 who are in Malaysia without any parents or close family members. One of the programmes SUKA provides for such persons is the community placement and case management services. Case management is where SUKA works with you to get access to needed services until your case is resolved (resettlement or repatriation) or when you age out of the programme (that is, you turn 18 years old), whichever happens first. Community placement is where SUKA works with adults in your community to be your foster parents to provide care and protection.

The services provided by SUKA will include:

1. Interviews to understand your needs and risks.

2. Care planning and goals development.

3. Referrals to organizations for support services, including health, education and welfare services.

4. Specific actions that fit your needs and address your problems.

5. Placement with foster parents.

6. Monthly checks to follow up on your progress.

7. Record keeping and monitoring of your case.

SUKA Society will work with non-government and community based agencies to help you achieve your individual goals and help you to move toward long-term self-sufficiency or case resolution. As no two cases are the same, services are flexible and will be created to fit your individual needs.

When you are admitted into SUKA’s programme you will be assigned a Case Manager. A Case Manager is a professional person whose role is to follow up on your needs, and work with you to achieve your goals. The Case Manager is not your caregiver, parent or a counsellor. All actions by the Case Manager are undertaken on behalf of SUKA Society. All decision making processes under the programme falls on SUKA Society’s management team. The Case Manager cannot provide personal services or gifts of a personal nature for you.

SUKA Society does not employ agents to work on behalf of the organization. SUKA Society also does not charge minors for its services. If you are asked to pay any money to access SUKA’s services, please do not do so. If you are approached by anyone saying they are an agent of SUKA, please inform a SUKA staff member.

This case management programme is based on a partnership between SUKA and you. To ensure effective implementation of this programme and to better provide and coordinate services for you, you must be willing and committed to work with SUKA and participate actively in this process. SUKA also requires that you remain honest and cooperative throughout the process.

Participation in this case management programme is voluntary. You can stop services or exit the programme at any time. However, like any programme, if you do choose to participate, there will be roles and responsibilities you need to undertake, and programme requirements you need to follow. Please think carefully before signing to decide if you are ready to participate actively in the programme, follow the programme requirements, and work with your Case Manager to implement your care plan.

CLIENT STATEMENT OF CONSENT

I, (print name) ________________________________ agree to cooperate with SUKA Society, follow programme requirements, and participate actively in this case management process.

I understand authorized Case Managers/staff of SUKA Society will provide services and/or referrals that are beneficial and as needed for my personal situation.

I understand this programme is a PARTNERSHIP between me and SUKA (and my Case Manager) and requires commitment from me and SUKA.

I understand the services that I will receive and that I will be informed of any changes made to these services.

I agree to share my personal information to SUKA and also understand that information from my records will be kept confidential and only be shared among SUKA Society staff as needed and as part of my support plan.

I understand that SUKA Society will obtain a separate consent for sharing of information with other service providers (third party disclosure form).

I understand that participation in this programme is voluntary and I may withdraw from this programme at any time.

I understand that SUKA Society has a reasonable right to share my personal information with relevant authorities in the following five instances:

1. There is a clear indication of my intent to cause self harm or to die by committing suicide.

2. There is a clear indication of my intent to cause grievous harm or abuse to another (physically, mentally, verbally, emotionally, and/or sexually).

3. There is disclosure of my ongoing abuse (physically, mentally, verbally, emotionally, and/or sexually) by another that requires intervention by the State.

4. SUKA Society is ordered by law to provide evidence in relation to my case.

5. There is disclosure of a crime or my intent to commit a crime.

I understand that I may make a complaint if my confidentiality is breached, if I am not satisfied with services I receive and/or following any misconduct by authorized SUKA Society staff.

All concerns that I have regarding SUKA Society’s programme has been fully answered at this time. If I have additional questions, I understand that I am able to contact my Case Manager.

Signature: _________________________________________ Name: _________________________________

Date: _________________________________________

The following document was translated by:

Signature: __________________________________________

Name: _______________________________________________ Date: _______________________________________________

PARENTAL/ GUARDIAN CONSENT (where relevant)

I understand the above conditions set by SUKA Society and agree that my child/the minor under my care (print name) ______________________________ will receive the relevant services accordingly, subject to the conditions above.

Signature of Parent/Guardian: _________________________________________

Name: _________________________________________

Date: _________________________________________

The following document was translated by:

Signature: __________________________________________

Name: _______________________________________________ Date: _______________________________________________

10.20 Annex 16: Client Consent Form – Sharing of Information with other Agencies [Download]

THIRD PARTY DISCLOSURE

Where possible, please ensure that the following consent form is translated and printed in a language that the client/parent understands. Please also ensure that the form is read out and clearly explained to the client.

Name of Client: ______________________________________ Case Ref. No.: ___________________

Date of birth: ____________________________________ UNHCR No.: _____________________________

I hereby authorize SUKA Society and the following agency/agencies:

______________________________________________________________________

to carry out the following actions:

• Share and receive information on my case related to biodata, contact information and reasons for referral.

• Share and receive information on my specific needs disclosed during my interview.

• Share and receive information on decisions undertaken by relevant agencies in relation to my needs.

• Share and receive relevant personal documents submitted to listed agencies.

• Share and exchange any other information, where relevant, related to my case but not for the following listed information (please indicate NONE if there are no exceptions):

__________________________________________________________________________________________________________________

I understand that this consent will be effective for the period from ___________________ (date) to _______________________ (date)

I understand that I may inform a SUKA Society Case Manager at any time should I choose to amend the terms of this consent or revoke this consent.

Client’s signature: ________________________________ Date: ____________

The following document was translated by:

Signature: ___________________________

Name: _______________________________

Date: _______________________________

10.21 Annex 17: Full Client Individualized Care Plan Template (Excel document) [Download]

Planning	Implementation	Monitoring
Case ref. no. and client info	Identified needs and risks	Identified goals	Outcomes	Action plan (include strategies and referrals)	Timelines	Specify roles (of referral agencies, client, Case Manager, etc.)	Completion (X or √)	Case review (evaluate progress, outcomes vs. goals)	Significant changes in client’s circumstances	Observation of changes and re-evaluation of strategies/goals/ outcomes

10.22 Annex 18: Goals Development/Care Plan Template [Download]

Planning	Implementation
No.	Identified needs and risks	Identified goals	Expected outcomes	Action plan (include strategies and referrals)	Timelines	Responsibility (referrals, client, CM)	Completion (X or √)
	Housing
	Legal status
	Physical health
	Mental health
	Education
	Employment
Planning	Implementation
No.	Identified needs and risks	Identified goals	Expected outcomes	Action plan (include strategies and referrals)	Timelines	Responsibility (referrals, client, CM)	Completion (X or √)
	Welfare needs – food, clothing, hygiene
	Social support
	Family Tracing
	Any other need (e.g. case resolution/ durable solution)
Developed and acknowledged by:
Case Manager: Date:	Child: Date:	Foster Parent: Date:
Reviewed by:	Remarks
Supervisor: Date:

10.23 Annex 19: Sample Goals Development/Care Plan [Download]

Planning	Implementation
No.	Identified needs and risks	Identified goals	Expected outcomes	Action plan (include strategies and referrals)	Timelines	Responsibility (referrals, client, CM)	Completion (X or √)
	Housing - overcrowded - single men - no caregiver - cannot afford rent	To find safer housing with someone to look after him/her	Safe home environment and stability in placement	Find a suitable foster family	Within the month	Case Manager Client Community leader Foster parents
	Legal status - undocumented	To clarify legal status to be able to reside in Malaysia legally	Stability and safety from arrest and detention	Referral to UNHCR for clarification of legal status	Immediately (within 3 days)	Referral – CM UNHCR AAM
	Physical health - never had a health check	To obtain a proper health assessment	Good physical health	Referral to a health NGO	Within the month	Referral – CM Health NGO
	Mental health - SVT - misses family and home - feels guilty for leaving family	To be able to cope with feelings of being separated from the family	Better overall mental health – feel better about self	Referral to MH NGO/ psychologist/ counsellor	Within the month	Referral – CM MH NGO Client
	Education - illiterate	To be able to read and write and speak English	Literate and able to converse with other people	Referral to a school	Within 2 weeks	Referral and school items -CM NGO school/ teachers Client
	Employment - none at the moment	To develop skills to find a job once he/she ages out	Will be able to find a job on turning 18	Exploring skills based learning options	Over the year	CM NGO partners
	Welfare needs – food, clothing, hygiene - no food support - needs clothing and hygiene items	To be able to have nutritious food and adequate self-care items	Has adequate food, clothing and hygiene items	Monthly food provision based on client’s needs	Food within 1 week Clothing and hygiene items - within the month	CM Donors Client
	Social support - no friends - no one to talk to when feeling sad	To have a strong support system in the community	Cope better and able to do some fun activities	Introduction to other minors in the programme and the community organization	Within the month	CM Client Other minors Community leader
	Family tracing - lost contact with family members after fleeing country	To be able to find family members	Cope better with current circumstances	Referral to ICRC to initiate tracing process	Within 3 months	Referral – CM ICRC Client
	Any other need - no clear durable solution/case resolution	To be able to have a preparation/pathway to reach longer term solutions	More hope Longer term planning	Reassessed after legal status clarified	Over the case cycle	Client CM Relevant partners

• Initiate the foster care placement process

• Provide support to pay rent

• Referral to AAM for legal aid services

• Follow up on treatment where needed

• Follow up on therapy where relevant

• Monitoring of attendance and lessons

• Provision of writing and school materials

• Provision of hygiene items, once in two months

• Provision of clothing after sponsorship is obtained

• Assistance with tracing activities where relevant

• Preparation with skills for adult living

10.24 Annex 20: Intervention Referral Form [Download]

NAME OF CLIENT:

UNHCR NO.:

YEAR OF BIRTH:

CASE REF. NO. :

TELEPHONE NO.:

LANGUAGES SPOKEN:

Dear Sir/Madam,

(Name of client) is being referred by SUKA Society for the service/s outlined below.

If you require further information, please contact: (Case Manager’s name) by telephone: or email:

DETAILS OF SERVICE REQUIRED FROM REFERRAL AGENCY: Sample: Counselling for SGBV trauma experienced in country of origin as a young child and prior to him/her leaving the country
ANY OTHER RELEVANT INFORMATION: Sample: Client is a separated minor who has not received any counselling in the past. XX Agency has referred her to YY Agency for SGBV counselling; however minor has requested that, if possible, counselling be conducted at the ZZ Agency which is closer to her home.

Please note this referral has been agreed to ONLY verbally by the client. Please enquire with the client if he/she still wishes to have counselling. Thank you. [delete if not applicable]

Signed (Case Manager): _____ Date:

Signed (Client): _____________________________ Date: __________________________

10.25 Annex 21: Safety Plan and Care Provider Emergency Planning Template [Download]

A Safety Plan is required for all UASC. The Safety Plan is a written arrangement between the caregiver, the child and the Case Manager that identifies how safety threats to a child will be immediately controlled and managed.

Case Ref. No.	Case Manager	Type of Safety Plan

• Foster Care Home

• Independent Living Home

• In-Home Care (Kinship care)

Safety Plan Participants
Name	ID. No.
Safety Activities/Tasks
Identified safety threat 1: Frequency: (The number of times the threat is likely to occur)
Goal: (What do you want to achieve?)
Mitigating the threat: (Describe activities/tasks that will be undertaken to manage the child’s safety)
Who will mitigate?
Timeline: Start date: _______________________ Target end date: _____________________________
Identified safety threat 2: Frequency: (The number of times the threat is likely to occur)
Goal: (What do you want to achieve?)
Mitigating the threat: (Describe activities/tasks that will be undertaken to manage the child’s safety)
Who will mitigate?
Timeline: Start date:_______________________ Target end date: _____________________________
Identified safety threat 3: Frequency: (The number of times the threat is likely to occur)
Goal: (What do you want to achieve?)
Mitigating the threat: (Describe activities/tasks that will be undertaken to manage the child’s safety)
Who will mitigate?
Timeline: Start date: _______________________ Target end date: _____________________________
Identified safety threat 4: Frequency: (The number of times the threat is likely to occur)
Goal: (What do you want to achieve?)
Mitigating the threat: (Describe activities/tasks that will be undertaken to manage the child’s safety)
Who will mitigate?
Timeline: Start date: _______________________ Target end date: _____________________________
Additional comments: (Other safety related information regarding the placement)
Emergency numbers and contact resources
Emergency contact numbers: 1. _____________________________________ 2. _____________________________________	Resource Person 1 Name: Telephone no.:
Resource Person 2 Name: Telephone no.:	Resource Person 3 Name: Telephone no.:
Plan developed by: Plan completed on: Status of plan:	Signatures: Date: Case Manager:
	Caregiver:
	Child:

• Initial

• Revision

10.26 Annex 22: Tracing, Placement and Family Reunification Tool [Download]

¹⁹Information is to be filled in as comprehensively as possible. All information must be kept confidential. Interviewers should ensure that the client has signed all necessary consent forms.

REFERRAL AGENCY/CASE MANAGER INFORMATION
Name:	Designation:
Agency:	Case Ref. No.:
Email:	Telephone no.:
Signature:	Date of interview:
Has the client been provided necessary informed consent to be interviewed? YES NO
CLIENT PERSONAL BIODATA
Name (including all aliases):	Sex: (M/F)
Date of birth:	Place of birth:
Ethnicity:	Religion:
Country of origin:	Nationality:
Legal status:	Identification/Passport/UNHCR Number:
Languages spoken:	Level of education and last schooling:
Height:	Weight:
Hair colour:	Eye colour:
Skin colour:	Any identification marks:
Any impairment/disability:
Last known address/ Where the child was found:
Telephone no.:
TRAVEL/ENTRY INFORMATION
Date of arrival in Malaysia:	Exact place of arrival:
Describe travel or entry route (include mode(s) of travel and countries in transit):
Why did you leave your home country?
List persons accompanying the client on the journey into Malaysia: 1. 2. 3.	Relationship to client: 1. 2. 3.	Contact information: Where can we find them? 1. 2. 3.
What happened to these persons who accompanied you? (Are you still in contact with them?):
Circumstances and reasons of separation:
Do you have any relatives/friends in Malaysia? (Names and contact information, if available):
PARENTAL AND CAREGIVER INFORMATION
BIOLOGICAL FATHER
Name of biological father:	Status: Alive Deceased Unknown If deceased list date of death:
Identification/Passport/UNHCR Number:	Nationality:
When did you last see your father? (date and time)
Where did you last see your father? (place)
How did you separate from your father?
Where do you think your father is now?
Last known address:
Last known telephone contact number:
Last known place of work/employer details, if relevant:
BIOLOGICAL MOTHER
Name of biological mother:	Status: Alive Deceased Unknown If deceased list date of death:
Identification/Passport/UNHCR Number:	Nationality:
When did you last see your mother? (date and time)
Where did you last see your mother? (place)
How did you separate from your mother?
Where do you think your mother is now?
Last known address:
Last known telephone contact number:
Last known place of work/employer details, if relevant:
SIBLINGS (add rows if needed)
Name	Age and Sex	Status (alive, deceased, unknown)	Legal status (any I.D. no.)	Current location (Address)	Current telephone number
CURRENT CAREGIVER INFORMATION
Name of the person who is currently taking care of you:	Relationship to client:
Identification/Passport/UNHCR Number:	Nationality:
Sex (M/F):	Age/Date of birth:
Current address:
Caregiver telephone number:
Last known place of work/employer details, if relevant:
What is your relationship with your caregiver like? (any concerns/problems):
If client is living with someone else other than the caregiver
Name of person(s) you are currently living with:	Relationship to client:
Identification/Passport/UNHCR Number:	Nationality:
Sex (M/F):	Age/Date of birth:
Current address:
Telephone no.:
Reasons why the client is living with this person and not with the caregiver:
TRACING AND REUNIFICATION
Do you want to be reunified with your family? YES NO
If yes, who do you want to be reunified with?	If no, why?
Name:
Relationship:
Last known address/location:
Last known telephone contact number:
Is tracing currently being done by any other agency? YES NO
If yes, name of agency/Case Manager:	Contact information of agency/Case Manager:
What is the current status/result of prior tracing initiatives:?

10.27 Annex 23: Sample Independent Living House Rules [Download]

These house rules are set by the management of SUKA Society for the following apartment ______________________________________________ and effective on this date _____________________. All residents residing in the apartment are expected to follow the rules listed below and carry out relevant tasks accordingly.

General rules

1. No male/female outsiders or friends (who are not unaccompanied minors under SUKA’s Programme) are allowed to visit and/or stay overnight without express permission from SUKA Case Managers.

2. No resident is allowed to bring male/female outsiders, strangers, friends, relatives or minors with the intention to facilitate or engage in inappropriate behaviour such as gambling, stealing, consumption of alcohol, usage of prohibited drugs, and participation in sexual activity inside the house.

3. No smoking inside the house.

4. No destruction of property, including furniture and other structures in the house, as well as property belonging to other residents. Should property be destroyed, the said resident may be required to pay for damages accordingly.

5. No wasting of food, electricity, water and gas. All electrical switches must be turned off when not in use.

6. One access card is allocated per room. Residents must take turns holding the access card and no one resident should have control over the card for a long period of time. Residents must make sure not to lose the access card. The cost for replacing the card will be borne by residents in the apartment.

7. For your own protection and safety, curfew for all minors under SUKA’s programme is 8 pm. Residents must inform any of the housemates where they are if you are unable to make it home before the curfew time.

8. A duty roster will be drawn up to ensure that the apartment is clean at all times and tasks are equally shared. Duties must at least include cleaning of the house and cooking. All residents must comply with the duty roster that is drawn up. Arrange with your housemates to change your duty or task when you cannot make it for valid reasons.

9. Scheduled monthly home visits will be conducted by SUKA Case Managers. Surprise home visits may also be conducted at the discretion of the SUKA Case Managers.

Consequences for breaking House Rules:

Consequences for breaking the House Rules above will depend on the frequency and severity, and will vary on a case to case basis. The consequences, however, will not affect access to basic services or the resident’s case processing with UNHCR. The repeated breaking of these house rules may result in expulsion or removal from the house and/or SUKA’s programme, depending on the severity of the case.

Good practices when living with others:

1. No sleeping in the hall during the day as it is a common area.

2. Show respect to others if you want to be respected.

3. Clean up after yourself. If you use something, clean it and put it back. Be responsible for your own things.

4. When you feel sad or angry, talk to someone instead of taking it out on your housemates. Make an appointment to see a counsellor, talk to your friend, or do something that you are interested in, like drawing, sports, etc.

5. Be positive and do something nice for the people you stay with. Always try and be encouraging and positive with your roommates. Help them when they are in trouble. They are like your family here.

6. Be punctual and make sure you are on time for all appointments. Don’t keep people waiting for you.

Handling disagreements:

1. Accept and acknowledge the problem or issue.

2. Talk to the person you have a disagreement with and try to be open.

3. Listen to his/her side without judgement.

4. Come up with possible solutions together.

5. If the person is defensive or aggressive, and does not listen or cooperate then ask for the Case Manager’s help to intervene.

6. Do not delay. Try to resolve the issue as soon as possible.

Agreed and acknowledged by the residents/occupants:

Names Signature Date

1.____________________________ ___________________________ _______________

2.____________________________ ___________________________ _______________

3.____________________________ ___________________________ _______________

4.____________________________ ___________________________ _______________

5.____________________________ ___________________________ _______________

Prepared by: Approved by: Translated by:

___________________ ________________________ ______________________

Case Manager Case Supervisor Translator

10.28 Annex 24: Sample Physical Health Assessment Checklist [Download]

All information on this checklist MUST be kept confidential at all times. Consent must be obtained from the client if there is a need to disclose any information on this checklist²⁰

Name of client: Case number:

Sex: Male Female Date of birth:

Ethnicity/Country of origin: Language:

Client contact number:

Case Manager: Contact number:

Has medical consent been obtained? Yes No

A. GENERAL HEALTH AND LIFESTYLE

1. 1. Do you have any diagnosed physical illness or condition?

   Yes No

   2. If yes, please give details (include both minor and serious conditions):
2. 1. If you have a diagnosed physical illness/condition, are you receiving treatment?

   Yes No

   2. If yes, please give details of type of treatment and for which condition:
3. 1. Do you have a disability or impairment?

   Yes No

   2. If yes, please give details:
4. 1. Does any of your immediate family or deceased relatives (parents or siblings) have any physical illnesses/conditions?

   Yes No Unknown

   2. If yes, please give details (include both minor and serious conditions):

5. Please list all medications you are currently using:

Name of medication	Dose/Frequency	Condition	Start date

6. 1. Do you have any problems/side effects with any of these medications?

   Yes No

   2. If yes, please give details:

7. Diet - Can you give examples of what you eat on a typical day?

8. 1. Do you do any physical activity or exercise?

   Yes No

   2. If yes, what do you do and how often do you do this?
9. 1. Do you smoke cigarettes?

   Yes No

   2. If yes, how much do you smoke per day?

   3. Do you want to stop smoking?

   Yes No

   4. If yes, is there any particular help that you would like with this?
10. 1. Do you drink alcohol?

    Yes No

    2. If yes, what and how much or how often do you drink?
11. 1. Do you use recreational or non-prescription drugs?

    Yes No

    2. If yes, what do you use and how often do you use them?
12. 1. Do you know if you have any sexually transmitted disease?

    Yes No

    2. If yes, please elaborate:

    3. If yes, are you on medication?

    Yes No

    4. If yes, please elaborate:

    5. If no, please explain reasons why you are not on medication:

13. 1. Do you have any other concerns about any medical issues or do you need any further medical information?

    Yes No

    2. If yes, please give details:

    

    B. PHYSICAL SYMPTOMS CHECKLIST

    Using numbers indicate areas on the body where you experience current or regular pain, discomfort or difficulties in your body. Fill in more details about the problem in the box below:

Number	Problem/ difficulties	How often	Impact

C. SCREENING CHECKS

1. 1. Since arriving in Malaysia, have you visited a doctor/hospital/clinic?

   Yes No

   2. If yes please provide details:

Date/Time	Type of facility (Government, private clinic, NGO clinic)	Reason for visit

2. 1. Since arriving in Malaysia have you visited a dentist/had your teeth checked?

   Yes No

   2. If yes please provide details:

Date/Time	Type of facility (Government, private clinic, NGO clinic)	Reason for visit

3. 1. Since arriving in Malaysia, have you had a blood test done?

   Yes No

   2. If yes please provide details:

Date/Time	Type of facility (Government, private clinic, NGO clinic)	Do you have the results?

4. 1. Since arriving in Malaysia, have you had your eyes tested?

   Yes No

   2. If yes please provide details:

Date/Time	Type of facility (Government, private clinic, NGO clinic)	Do you have the results?

Record the following information where possible:

Height (m/cm): Weight (kg):

Calculate BMI: Waist measurement (cm):

Blood pressure:

Are there any other issues that we have not covered that you are concerned about? (Please list)

D. HEALTH ACTION PLAN

Based on the Assessment, develop a health action plan for treatment and referral of services

Health need identified	Action to be taken	Responsibility	Timeline for action	Follow up (when and who)	Any other comments

10.29 Annex 25: Client Medication Chart/Tracker [Download]

DAY	√	MEDICATION	DOSE	TIME		√	MEDICATION	DOSE	TIME
MONDAY
TUESDAY
WEDNESDAY
THURSDAY
FRIDAY
SATURDAY
SUNDAY
Medication name
Monday count
Sunday count
Pills taken
Refill needed?	⎕ Yes ⎕ No	⎕ Yes ⎕ No

Child’s Signature:

Case Manager’s Signature:

Case Reference No.:

10.30 Annex 26: Home Visit Checklist [Download]

Case ref. no.: ______________________________________________ Date: _______________________

General location: ________________________________________ Home visit completed by: _________________________

Announced Unannounced Food support provided: Yes No

NO.	HOME ENVIRONMENT/SAFETY	YES	NO	N/A	NOTES/FOLLOW UP
1.	Is the home reasonably clean and uncluttered?
2.1	Is the home well maintained?
2.2	If no, what repairs are needed?
2.3	How is this being addressed?
3.1	Are there identifiable escape routes?
3.2	Can the minor describe the escape routes?
4.1	Can the minor/caregiver handle minor medical needs?
4.2	Can the minor describe what to do in a medical/ safety emergency?
4.3	Are the emergency telephone numbers available/ clearly visible?
5.1	Is there sufficient food in the home?
5.2	Can the minor store food safely/cleanly?
5.3	Are there cooking safety issues/fire hazards?
5.4	If yes, how is this is being addressed?
6.1	Are there bathing safety issues?
6.2	If yes, how is this is being addressed?
NO.	SURROUNDING ENVIRONMENT/SAFETY	YES	NO	N/A	NOTES/FOLLOW UP
1.	Is the surrounding environment of the house/ apartment reasonably clean and uncluttered?
2.1	Is the security of the surrounding environment adequate?
2.2	If no, what is being done to address this?
NO.	MEDICATION	YES	NO	N/A	NOTES/FOLLOW UP
1.	Does the minor self-medicate
2.	Does someone assist the minor with medication?
3.	Does the minor or the caregiver know of the necessary dosage and timings of the medications?
4.	Are medications stored safely?
5.	Are there any expired medications?

Foster Care Home Visit Checklist

Name of child: Case referral no.:

Name of Foster Parents:

Address of home visited:

Date of visit: Time of visit: From _______________to _________________

Name of Case Manager making the visit:

Name of interpreter (if applicable):

Was the child present during the visit? ⎕ Yes ⎕ No

If no, why?:

List the foster family members present during the visit:

__________________________________________________________________________________________________________________

Home Environment

A. Facilities in the home

Facilities Provision
1. Is everything that was agreed on still maintained?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?
Facilities Access
1. Is everything that was agreed on still available for access?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?

B. Basic needs

Needs Provision
1. Is everything that was agreed on still maintained?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?
Needs Access
1. Is everything that was agreed on still available for access?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?

C. Cleanliness and maintenance in the home

1. Is the home well maintained?	⎕Yes ⎕No
2. Is the home clean?	⎕Yes ⎕No
3. If no, what are the recommendations to fix the problem?
4. If unable to fix or comply with recommendations, why?
5. What mitigating steps are to be taken to resolve the issue?

D. Safety concerns in the home

1. Are there any new safety concerns related to the facilities?	⎕Yes ⎕No
2. If yes, what are these concerns?
3. What mitigating steps are to be taken to resolve the issue?

E. Household members

1. Are there any changes to the family composition?	⎕Yes ⎕No
2. If yes, who are they, and what is the relationship?
3. Does the presence or absence of new or existing persons affect the placement?
4. What mitigating steps are to be taken to address the issue?

External Environment

A. Facilities outside the home

Facilities Provision
1. Is everything that was agreed on still maintained?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?
Facilities Access
1. Is everything that was agreed on still available for access?	⎕Yes ⎕No
2. If no, what specifically has changed?
3. Why has it changed?
4. How does this affect the child negatively?
5. What mitigating steps are to be taken?

B. Cleanliness and maintenance outside the home

1. Is it well maintained?	⎕Yes ⎕No
2. Is it clean?	⎕Yes ⎕No
3. If no, what are the recommendations to fix the problem?
4. If unable to fix or comply with recommendations, why?
5. What mitigating steps are to be taken to resolve the issue?

C. Safety concerns outside the home

1. Are there any new safety concerns related to the facilities?	⎕Yes ⎕No
2. If yes, what are these concerns?
3. What mitigating steps are to be taken to resolve the issue?

Placement Relationship (group and individual interviews with foster parents and child)

Group interview:

1. Communication - updating on progress and needs

2. Strength of the relationship

3. Meeting of expectations and needs from the placement

4. Challenges and conflict

5. Activities carried out together

6. Challenges in meeting care plan goals

7. Concerns or questions about the foster care placement

8. Positive highlights about the placement

9. Recommendations for improving the foster care process

Individual interview:

1. Any other expectations

2. Conflicts and challenges

3. Additional support that is needed - resources for parent and child, and training for the parents

4. Changes in circumstances that affects the placement

Monitoring Checklist for Case Manager

1. Date of previous visit:
2. Have issues from the previous visit been resolved?	⎕Yes ⎕No
3. If no, what issues are pending?
4. What mitigating steps are to be taken to resolve the issue? a. b. c.	Timeline to resolve the issues

Prepared by:

Name of Case Manager:

Signature:

Date:

10.31 Annex 27: Case Notes/Monthly Home Visit Template [Download]

Case number/Ref no.: Name of Case Manager:

Date and time of visit: Food support provided?: Yes/No

No.	Area of Need	Notes
1.	Housing/Placement
2.	Legal status
3.	Physical health
4.	Mental health
5.	Education
6.	Employment
7.	Welfare needs
8.	Social support
9.	Family tracing
10.	Any other needs (e.g. case resolution/durable solution)

Summary of Course of Action/Follow up:

Case Manager’s Signature: Date:

10.32 Annex 28: Progress Notes Template [Download]

²¹Case number/Ref. no.: Date of visit/interview:

Strengths	Objective account	Assessment	Plan
List strengths observed	Provide an objective account of your interaction with the child during the interview/home visit	Your assessment of the situation/individual (based on objective account)	Client progress towards achieving agreed goals
Note: New information gathered on your visit/during an interview.

Progress notes prepared by: __________________________________ Date: _________________________

Progress notes reviewed by: ________________________________ Date: _________________________

10.33 Annex 29: Client Exit Form [Download]

Name of client:

Date of termination:

Case ref. no.:

Reasons for termination:

• Resettlement (country: ______________________________________)

• Repatriation to home country

• Successful local integration (state the method e.g. work permit, permanent residency, etc.) _________________________________________________________________________________________

• Successful integration with caregiver or family

• Client is 18 years of age

• Client is deceased (illness, accident or victim of crime)

• Client is no longer interested in case management services

• Lost contact with client or whereabouts of the client is unknown

• Others (please specify): _____________________________________________________________________________

Forwarding address (if known):

Contact number (if known):

1. What have you achieved?

2. What goals are you still working on?

3. Are you currently employed?

• Yes

• No

4. Do you require any follow up support?

• Yes

• No

If yes, please specify:

Foster Care Exit Form

Name of foster child: Case reference no.:

Name of Foster Parent 1: Name of Foster Parent 2:

Date of admission into Programme: Date of placement termination:

Reasons for placement termination:

Overall experience of the Programme (both parties)

1. From your experience, please share the highlights of the programme.

2. From your experience, please share the low points of the programme.

3. Please share some benefits of the programme (particularly with regards to the placement and the organization).

4. Please share some drawbacks of the programme (particularly with regards to the placement and the organization).

5. What can we improve or how can we make this programme better?

6. For the Foster Parents, please share what could you have done better in the programme.

7. For the Foster Child, please share what could you have done better in the programme.

8. For both parties, how did you feel about the services/assistance from the following:

   1. External partners

   2. Organization’s personnel (Case Manager, Foster Parents Support Worker)

9. For both parties, how do you think the following persons/agency can improve the services/assistance:

   1. External partners

   2. Organization’s personnel (Case Manager, Foster Parents Support Worker)

Feedback on Care Plan

For the child:

1. Goals achieved from your care plan (please list briefly):

   1. ________________________________________________________________

   2. ________________________________________________________________

   3. ________________________________________________________________

   4. ________________________________________________________________

   5. ________________________________________________________________

2. Goals not achieved from your care plan

   1. ________________________________________________________________

   2. ________________________________________________________________

   3. ________________________________________________________________

   4. ________________________________________________________________

   5. ________________________________________________________________

3. What do you feel about these goals that you have achieved and those that you have not achieved?

4. What helped you in achieving some of your goals?

5. What could have been done better to help you reach the goals?

6. What goals will you continue to work on after exiting the programme?

7. What support do you need to continue to achieve these goals after you have exited the programme?

For the foster parents:

1. How have you helped your foster child achieve some of these goals?

2. What do you think you could have done better?

3. What improvements can the programme make to assist a foster child in achieving these care plan goals?

Final feedback

For the child:

1. Would you recommend the programme to other unaccompanied and separated children?

⎕ If yes, why? ____________________________________________________________________________________________________________________________________________

⎕ If no, why?

____________________________________________________________________________________________________________________________________________

For the foster parents:

1. Do you want to continue to participate in future placement of foster children in your home?

⎕ If yes, why? ____________________________________________________________________________________________________________________________________________

⎕If no, why?

____________________________________________________________________________________________________________________________________________

1. Would you recommend the programme to other parents? ⎕ Yes ⎕ No

Any other comments/feedback (both parties):

For office use

Exit interview completed by:

Date:

Method of completion:

⎕ Verbal (written) ⎕Self-completion ⎕Recording (voice/video)

10.34 Annex 30: Client Feedback Form [Download]

Please complete this form and place it in the sealed envelope provided. Your feedback is important to help us improve our services. All responses will be kept confidential. You do not need to put your name on the form. Thank you.

1. What kind of assistance or services did you expect from this programme?

2. 1. Did the services or assistance under this programme generally meet your expectations?

   (Please tick)

• Expectations fully met Expectations partially met □ Expectations not met

2. If you ticked Expectations partially met, please elaborate which expectations were not met:

3. If you ticked Expectations not met, please elaborate how these services did not meet your expectations:

1. Please provide feedback on the following specific areas under the programme:

2. Were you satisfied with your Case Manager?

Yes Partially No Not applicable

Additional comments:

1. Was your privacy and confidentiality respected at all times?

Yes Partially No Not applicable

Additional comments:

1. Did you feel you were treated fairly and without discrimination?

Yes Partially No Not applicable

Additional comments:

1. Did you feel your needs were met?

Yes Partially No Not applicable

Additional comments:

1. Did you feel you were adequately informed of services and the outcomes of your case in a timely manner?

Yes Partially No Not applicable

Additional comments:

1. Did you find having an individualized care plan helpful?

Yes Partially No Not applicable

Additional comments:

1. Did you feel you were adequately consulted and given the opportunity to participate in the development of your care plan?

Yes Partially No Not applicable

Additional comments:

1. Did you find home visits by the Case Managers helpful?

Yes Partially No Not applicable

Additional comments:

1. Did you feel there was continuous follow up on your progress?

Yes Partially No Not applicable

Additional comments:

1. What are some of the strengths of the programme? (what was most beneficial for you):

2. What are some of the drawbacks of the programme? (what was least helpful for you):

3. Please provide suggestions on how we can improve our programme.

4. Any other comments:

10.35 Annex 31: Sample Termination Letter [Download]

By Hand

Case Ref No.:

Date

Dear Mr./Ms. xxx,

Transitioning out of SUKA Society’s Community Placement and Case Management Programme

We would like to firstly express our gratitude for your participation in SUKA Society’s Community Placement and Case Management Programme. You were first admitted into SUKA’s programme on xxx. During this almost xx year journey, you have participated actively in the process, cooperated and worked well with your Case Manager, and worked hard in achieving your case goals. With this hard work and participation in the process, you have achieved some major milestones: including being recognized as a refugee, resolution in your health issues, tracing and establishing contact with your mother in xxx, learning and speaking English, and the development of your talent/skills in art.

As you are aware, SUKA Society’s programme is specifically for unaccompanied minors under the age of 18. Given your current age, this means that the organization has to implement a transition and discharge process for you to exit SUKA Society’s programme. This discharge process is a standard organizational practice for minors who turn 18. The purpose of this six-month process is to provide support to minors to transition out of SUKA’s programme into independent living as they become young adults.

However, following your conversation with your Case Manager earlier this month, we understand that you want to waive this six-month transition process and wish to terminate support from SUKA with immediate effect. We understand that this is because you have found a stable job, and are earning a decent income that will allow you to support yourself. We also understand that you are making this decision to enable other minors below the age of 18 or new arrivals to obtain support from SUKA as you did when you first arrived. This is an admirable decision to make.

On that note, we will respect your decision to waive the six-month support. However, during this six-month period (xxx), should you encounter any challenges in your current situation, you can reach out to SUKA Society Case Managers for advice and assistance. We are happy to continue to support you during this phase, where needed, including obtaining updates on your case process with UNHCR.

We hope that this case management process has been a positive experience for you generally. Your Case Manager reports that from the point of intake to this date you have matured immensely and shown independence. You have shown a great deal of responsibility and appear more empowered to make appropriate decisions. We wish you all the best in your future endeavours and journey into adulthood.

Should you have any questions regarding the content of this letter please contact your Case Manager, xxx. Once again thank you for your positive participation in the programme.

Yours sincerely,

___________________________

Executive Director

SUKA Society

10.36 Annex 32: Sample Recommendation Letter [Download]

By Hand

Case Ref. No.:

Date:

Dear Sir/Madam,

Reference letter for xxx (UNHCR No: xxx)

SUKA Society is pleased to write this reference letter for Mr. xxx (UNHCR No: xxx). Mr. xxx has been a client of SUKA Society’s Community Placement and Case Management Programme for unaccompanied and separated minors in Malaysia from xxx until his departure to the xxx in xxx. During this time, we have seen Mr. xxx develop and become a more empowered young man.

Mr. xxx has shown great strength and tenacity to rise up against the adversities and persecution he faced in his home country and in Malaysia. Despite a lack of legal status, Mr. xxx refused to rely solely on handouts or support from non-governmental organizations and worked multiple informal jobs to support himself during his stay in Malaysia. On these jobs, he worked hard and learned quickly, picking up various skills, including basic mechanical and electrical skills, and heating and ventilation ductwork installation. We believe that with more formal training and the right guidance to build upon these skills, Mr. xxx will pick up the trade very quickly and become an asset to the industry.

Although he was working and had no access to formal education, Mr. xxx was determined to learn English. He persevered and learnt Basic English and Mathematics from a community school after work hours and on his off days. Throughout the case management process, Mr. xxx has been honest, cooperated with his Case Manager, and took the initiative to work on his case goals. He has also been very helpful and went beyond what is required of him by assisting Case Managers with delivery of monthly food provisions for other minors in the area.

SUKA Society or Persatuan Kebajikan Suara Kanak-kanak Malaysia (SUKA) is a nationally registered Non-Governmental Organization (ROS: 2504-10-SEL) set up to protect and preserve the best interests of children. SUKA Society advocates for the survival, protection, participation, and development of all children, and provides welfare and community development programmes for children and their families. SUKA Society firmly believes that all children, especially those who are marginalised, should be empowered to grow and realize their full potential.

Please do not hesitate to contact his Case Manager, Ms. xxx via email (xxx) should you need further information or clarification.

Thank you

Yours sincerely,

_____________________

Executive Director,

SUKA Society

10.37 Annex 33: Key Foster Care Stakeholder Roles and Responsibilities [Download]

Foster Parents

Though not exhaustive, the list below provides some key roles and tasks expected of foster parents:

	Provide day to day care of the child in the foster parents’ home.
	Ensure that the child’s basic needs for food, clothing, health and shelter are met.
	Ensure that the home is warm, comfortable and welcoming for children.
	Ensure that the child is safe and they know that their overall well-being is cared for.
	Ensure that the child is welcomed as part of the family and household and that appropriate relationships are built with the child.
	Ensure that there is fair and equal treatment for all children in the home and that the UASC understands the family dynamics in the household.
	Ensure that the child’s privacy and confidentiality is respected.
	Ensure that there is open and respectful communication with the child.
	Ensure that the child knows that the foster parents regard the child as an individual, will listen to his/her opinions and speak for his/her benefit as and when necessary.
	Advocate for the best interest of the child and speak on behalf of the child placed under their care, especially for a child who is unable to communicate due to limitations in maturity and capacity.
	Support the UASC to reach his or her potential whilst helping the child understand that there are challenges in opportunities and resources.
	Support the child’s holistic development including social skills, relationships with others and self-care.
	Ensure that the child’s needs including health, leisure, social activities and education are adequately met when needed as how any reasonable parent would do so.
	Ensure that the child knows that the foster parents respect and encourage him/her to express his/her own individuality, personality and character.
	Ensure that the child knows that the foster parents respect and encourage him/her to develop a sense of identity and healthy acceptance of his/her own culture, tradition and religious background.
	Provide consistent discipline and guidance that is age appropriate and focused on behaviour and attitude change rather than punitive punishments.
	Ensure that foster parents prepare the UASC for independent living and adulthood.
	Understand and act in accordance with the standards, policies and procedures listed the in the Manual for Foster Care, Handbook, and relevant national laws and regulations.
	Observe and respond as how any reasonable parent would do in cases of medical emergencies or accidents. In all emergencies, the foster parents should notify the Foster Care Agency, Foster Parents Support Worker or Case Manager as soon as it is possible.
	Inform the Foster Care Agency or the Foster Parents Support Worker of any significant changes in their own life that may impact the care of the child.
	Contribute, put into practice, and work together with the child and the Case Manager to implement the child’s care plan.
	Ensure an open and positive working relationship with the relevant foster care personnel and the Foster Care Agency.
	Provide necessary feedback during monitoring and evaluation of the care plan, individual case evaluation and the overall foster care programme evaluation.
	Attend all training and development programmes organised by the Foster Care Agency and work towards putting the lessons learnt during training into practice.

The roles of a foster care personnel may differ based on the foster care model, programme and country context. Listed below are some key roles and responsibilities expected of each personnel within the foster care placement process:

Foster Parents Support Worker

	Conducts interviews and home visits of the prospective foster parents during the intake and selection process.
	Completes the comprehensive profile of the prospective foster parents (known as a Home Study) and convenes a meeting with relevant stakeholders to conduct the selection of the foster parents.
	Performs all necessary duties according to the standards and timelines required by the Foster Care Agency in recruiting prospective foster parents, selecting foster parents, organising the training for the foster parents, and supporting the foster parents through continuous training programmes and support groups.
	Works with the foster parents to identify and plug gaps with resources and tools that help them carry out their roles effectively.
	Encourages the foster parents to develop and maintain a healthy and positive relationship with their foster child.
	Conducts scheduled and unscheduled visits to monitor the effectiveness of the foster parents in carrying out their roles and responsibilities.
	Advises, guides and counsels foster parents to help them meet the Minimum Standards of Care.

Case Manager

	Ensures that the child’s referral, assessment, matching, placement, exit and follow up are carried out according to the agency’s standards.
	Conducts regularly scheduled and unscheduled visits to the foster home and checks with the child to ensure that the child is safe and that the Minimum Standards of Care are met.
	Works closely with the foster parents and the UASC in developing the care plan and putting it into practice.
	Encourages the child to develop and maintain a healthy and positive relationship with his or her foster parents and other family members in the household.
	Keeps the foster parents updated regarding the implementation of the care plan, the child’s status in the programme, the progress of case resolution, and any other issues raised during the Case Manager’s contact with the child.
	Works with the foster parents when unable to work directly with the child because of the child’s limited maturity or diminished capacity.
	Works with the Foster Parents Support Worker by providing necessary feedback from the child’s perspective in plugging gaps in care delivery by the foster parents.
	Regularly conducts care plan reviews with the child and foster parents.
	Supports foster parents during emergencies or whenever the child is ill and requires medical intervention.

Quality Assurance Worker

	Performs all necessary duties according to the standards and timelines required by the Foster Care Agency in carrying out individual case evaluation and overall programme evaluation.
	Develops and implements an appropriate individual case evaluation and overall programme evaluation tool that meets the needs of the programme and the Foster Care Agency.
	Works collaboratively with the other foster care personnel, foster parents and the child to obtain the necessary feedback on the individual placements and overall programme.
	Analyses the data collected and develops necessary reports for all relevant stakeholders on the effectiveness of the individual placements and the overall foster care programme.
	Uses evaluation reports to help the programme to better meet individual case goals and to improve delivery of services.

10.38 Annex 34: Minimum Standards of Care [Download]

No.	Standard	Description
	Promoting the child’s right to participation	Children have the right to participate in decision making processes that may be relevant to his/her life. This standard affirms that children have the right to be heard and that his/her opinions are given due weight in accordance with their age and maturity.
	Safeguarding children and ensuring that they remain protected	Children must be safeguarded at all times. This standard requires that children should grow up in circumstances consistent with the provision of safe living environments that are free from abuse, neglect and maltreatment.
	Preserving the culture, traditions, language, religious preferences and community links	Children have the right to practice their culture, traditions, language and religion, so long as these practices do not impede other people from enjoying similar rights.
	Fostering a positive self identity, willingness to achieve his or her potential, and valuing his or her own uniqueness	Children need to be in an environment where they can grow and reach their full potential. Such an environment encourages children to develop a positive self-identity and helps them value their own uniqueness.
	Nurturing positive values, attitudes, behaviours and relationships	Children should receive direction and guidance to grow and develop positive values, attitudes and behaviours. This standard respects the responsibility of the foster parents in providing guidance to the child under their care and expects that the foster parents will always consider what is in the best interest of the child when doing so.
	Promoting good health, appropriate standard of living and well-being	Children have the right to live in a healthy environment, be able to access healthcare services and enjoy a standard of living that adequately meets his/her physical and mental needs.
	Creating opportunities for rest, leisure and recreation	Children have the right to rest, play and to enjoy a wide range of cultural, artistic and other recreational activities.
	Promoting education and personal development	Children have the right to access primary education, other educational opportunities, and be supported to develop his/her potential to the fullest.
	Preparation for independent living and adulthood	This standard looks into the pathway to independent living which addresses the child’s education, training and employment, his or her community support, and the ability to manage finances. It also looks into the child’s health and personal development, such as developing the child’s ability to be resilient and to care for himself/herself.
	Mitigating potential risks and threats	This standard provides that relevant stakeholders must take reasonable precautions in assessing the degree of risks and threats the child might face and develop safeguards to reduce the likelihood of these risks and threats being realised.
	Conducting family tracing, supporting family contact, and exploring family reunification	Children, who are unaccompanied and separated, should not be separated from their parents against their will, and all efforts should be made to reunite the child with his or her parents as long as it is in the child’s best interest to do so.
	Maintaining good record keeping, confidentiality and privacy	Children have a right to privacy. All relevant stakeholders must maintain good records by having sound practices and policies about the handling of information and protect the confidentiality of information of the child.
	Supporting those with disabilities	Children who have any kind of disability have the right to special care and support. Special attention should be given to ensure that the child can live a full and independent life.
	Allegations and complaints	Children should know that their complaints are taken seriously, that all relevant stakeholders will work towards resolving the complaints in a just manner, and that there will not be any repercussions to the child for making a complaint.
	Conducting regular supervision, training and evaluation of foster parents and foster care personnel	Foster parents and foster care personnel play a central role in safeguarding children and promoting positive outcomes for them. As such, regular supervision, training and evaluation must be in place to ensure that foster parents and foster care personnel are effective in the work they do for children.
	Support through financial and material resources to maintain an acceptable standard of living	Foster parents from challenging backgrounds, such as asylum seekers, stateless persons and refugees go through significant financial hardship. As such, in countries where there is no aid given to asylum seekers, stateless persons and refugees, some form of support for foster parents must be incorporated into the programme.
	Conducting regular case reviews, effective case management and comprehensive programme evaluation	The programme must ensure that it has all the necessary processes it needs to conduct regular case reviews, effective case management, and comprehensive programme evaluation.

10.39 Annex 35: Foster Parents Application Form [Download]

Name of applicant (Father)
Age
Legal status	⎕Refugee ⎕Asylum seeker ⎕ Undocumented
UNHCR card no./ Community card no.
Telephone contact no.
Ethnicity
Religion
Employment status	⎕Employed ⎕Self-employed ⎕Unemployed ⎕Homemaker
Place of work (if applicable)
Type of work (if applicable)
Average monthly income
Languages spoken
Years in Malaysia
Name of applicant (Mother)
Age
Legal status	⎕Refugee ⎕Asylum seeker ⎕ Undocumented
UNHCR card no./ Community card no.
Telephone contact no.
Ethnicity
Religion
Employment status	⎕Employed ⎕Self-employed ⎕Unemployed ⎕Homemaker
Place of work (if applicable)
Type of work (if applicable)
Average monthly income
Languages spoken
Years in Malaysia

Household Members (Please include every person living in the home.)

No.	Name	Age	Relationship	Legal status	Employment status*

* Employed/Self-employed/Unemployed/Homemaker

House Details

Current address
Type of house
No. of years in the house
Type of tenure	⎕Main tenant ⎕Subtenant ⎕Owner ⎕Rent free
Rental per month (if applicable)
No. of bedrooms
No. of bathrooms/toilets
Kitchen facilities	⎕Yes ⎕No

Health Status

Do you or any person in your household suffer from any known physical or mental illness? (Yes/No)

If yes, please indicate in the table below:

No.	Name	Type of illness	Duration (years)	Treatment

Criminal Record Check

1. Have you or your spouse been investigated for a crime in any country?

⎕Yes ⎕No

If yes, provide details: ________________________________________________

1. Have any members in your household been convicted or charged for a crime in any country?

⎕Yes ⎕No ⎕Not sure

If yes, provide details: ________________________________________________

1. Have you or your spouse been accused, or investigated for any violence against a child (abuse, neglect, maltreatment, exploitation)?

⎕Yes ⎕No

If yes, provide details: ________________________________________________

1. Have any members in your household been accused, or investigated for any violence against a child (abuse, neglect, maltreatment, exploitation)?

⎕Yes ⎕No ⎕Not sure

If yes, provide details: ________________________________________________

Motivation

Please tell us why you would like to foster a child:

_________________________________________________________________________________________________________________________________________________________________________________________________________

References

Please list two referees who know you well enough to be able to recommend you for the programme. The referee must not be a family relation.

Name:

Address:

Telephone no.:

Email:

Occupation:

Organization affiliated with:

Name:

Address:

Telephone no.:

Email:

Occupation:

Organization affiliated with:

Declaration

1. I/We declare that the information given in this application is accurate and true to the best of my/our knowledge.

2. I/We understand that any incorrect or false information provided may disqualify this application from being considered.

3. I/We understand that information provided in this form will be kept confidential by the Foster Care Agency. However, I/we understand that the Foster Care Agency is unable to ensure confidentiality of information shared with the community representative that has assisted in the completion of this application.

4. I/We consent to the Foster Care Agency carrying out background checks and any other checks deemed necessary based on the information provided in this application form.

5. I/We consent to the Foster Care Agency contacting the references named on this application form.

Signature of Applicant 1: Signature of Applicant 2:

Date: Date:

Did you have assistance filling in this form? ⎕Yes ⎕No

If yes, please provide the following details:

Name (of the person who assisted):

Signature:

Telephone contact no.:

Date:

For Office Use

Date received:

Received by:

Name of assigned Foster Parents Support Worker:

10.40 Annex 36: Foster Parents Reference Form [Download]

REQUEST FOR PERSONAL CHARACTER REFERENCE FOR FOSTER PARENTS APPLICANTS

Name of Applicant (Father)	Name of Applicant (Mother)	Date of Application

The above applicants have applied to be foster parents for unaccompanied and separated children living in Malaysia. They have given your name to the organization as their personal referee. Please complete the following questionnaire based on what you know about both of them. Your honest responses are important to determine the best interest of the applicants and any potential foster child who may be placed under their care.

Kindly return the completed questionnaire to the organization at ___________________. If you have any queries or need more information, do not hesitate to contact ___________________ at ___________________. Thank you for taking time to assist us in this very important matter. We look forward to receiving your response.

Question	Name of Applicant [Father]	Name of Applicant [Mother]
How long have you known this person?	__ years ___ months	__ years ___ months
How did you come to know him/her?
How well do you know this person?	Extremely well	Extremely well
How often do you meet/contact him/her?	Always	Always
How would you rate him/her on these aspects?
Integrity (i.e., being honest and having strong moral principles)	Excellent	Excellent
Empathy (i.e., able to understand and feel what others are experiencing)	Excellent	Excellent
Ability to manage the household (i.e., housekeeping, home maintenance, finance)	Excellent	Excellent
Ability to care for children (i.e., providing nurture, guidance, protection, supervision, discipline, etc.)	Excellent	Excellent
Physical health	Excellent	Excellent
Emotional stability	Excellent	Excellent
Supportive ties with people from the community	Excellent	Excellent
To your knowledge, has he/she ever been convicted or charged with a crime?	Yes	Yes
To your knowledge, has he/she been investigated or accused of abusing or neglecting a child?	Yes	Yes
Would you recommend a unaccompanied or separated child to be placed with him/her in a foster care arrangement?	Yes	Yes
Any additional information or comments which will be helpful for the organization to consider?

• Moderately

• Somewhat

• Slightly

• Not at all

• Moderately

• Somewhat

• Slightly

• Not at all

• Often

• Sometimes

• Rarely

• Never

• Often

• Sometimes

• Rarely

• Never

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• Very good

• Good

• Fair

• Poor

• No

• No

• No

• No

• No

• No

Signature of referee:

Name of referee:

Date:

For Office Use

Date received:

Attention to Foster Parents Support Worker:

10.41 Annex 37: Basic Screening Criteria for Foster Parents in the Programme [Download]

BASIC SCREENING CRITERIA FOR FOSTER PARENTS IN THE PROGRAMME

	At least one of the parents must be registered with UNHCR or have some form of legal documentation.
	Both parents must agree to foster the child.
	Both parents must be above the age of 21 years.
	Parents must complete and submit the application form.
	Applicants must be recommended by a minimum of two referees.
	Parents should already have an income to partly support the foster child.
	Both parents and others in the household must declare any physical/mental health illness, particularly if they have any known communicable disease.
	The foster parents or any of the other family members should not have any criminal conviction, pending criminal charges, or current investigations related to violence against children.
	The foster parents must be of good character and reputation.
	The house to place the child must have adequate space and basic facilities.

ADDITIONAL FACTORS TO BE CONSIDERED FOR SELECTION OF FOSTER PARENTS

This is a list of additional factors for the selection of foster parents in terms of personal characteristics and attitude. These are to be identified during intake, developed during training, and assessed during selection. These factors will assess the needed personal characteristics and attitude to foster a child.

	They must demonstrate motivation and have good reasons for wanting to foster a child.
	They must demonstrate the ability to support the goals of safety, permanency, and well-being for the child.
	They must demonstrate maturity in terms of meeting the child’s best interest.
	They should demonstrate the ability to deal with challenges or stressors by the willingness to engage with people who can assist with the challenges or stressors.
	They should demonstrate adequate parenting skills and abilities to provide the necessary nurturing, discipline, and guidance appropriate to the age and functioning abilities of the child.
	They should have a reasonably positive and harmonious family environment.
	They must be willing to attend foster care trainings and support group meetings organised by the organization.
	They must be willing to work together with the Foster Parents Support Worker, the Case Manager, other organization personnel, partner agencies, and be open to receiving feedback and guidance when appropriate and necessary.
	They must be willing to work towards meeting the standards and procedures in the Manual and Handbook.
	They should have supportive community ties with friends and neighbours, at least within their own community.

10.42 Annex 38: Foster Parents Intake Form [Download]

APPLICANT 1 (FATHER) APPLICANT 2 (MOTHER)

Name: Name:

PART A: INTERVIEW

1. Demographic information

Inserted from the application form

1. History or background information

2. Education

• Did you go to school? If so, where did you study and what was the highest level completed?

• What was your experience of school?

1. Employment

• How long have you been working and what kind of work have you been doing?

• Are you working now? If so where are you working now?

• What do you do in your job?

• How is your relationship with your superior and/or co-workers?

• If not working now, what was your last job? - description, where, relationship with boss and co-workers.

1. Family background

• List immediate members of your family - including your relationship with these members, location, and names.

• Previous marriages and children from previous marriages.

• Describe the type of relationship with key members of your immediate family.

1. Reasons for leaving home country

• Why did you leave your country?

• How did you arrive in Malaysia?

• How long have you been staying in Malaysia?

• What did you have to do to survive in Malaysia?

1. Health

• Health concerns from country of origin (physical and mental health) - diagnosis, medication/treatment if any, period of illness.

• Health concerns in Malaysia (physical and mental health) - diagnosis, medication/treatment if any, period of illness.

• Have you had a health screening in Malaysia? Have you been to a hospital or clinic in Malaysia?

• Specific health concerns of any member of your household - diagnosis, medication/treatment if any, period of illness.

3. Support system

• How well do you know your neighbours?

• Who can you call for help if you are in need?

• How often do you participate in community events?

• Are you involved in any community projects?

The answers to the following questions are to be measured against the minimum standards expected of foster parents. The interviewer is expected to capture information or the narrative from the potential foster parents and flag any concerns where information or narration does not meet minimum standards. The interviewer is expected to provide justification for the red flags raised.

Min. Standards	Question(s)	Red Flags
4. Personal and emotional well-being
	a. What makes you happy?
	b. What makes you sad?
	c. What makes you angry? Can you describe a time which made you particularly angry? How did you manage your own anger?
	d. What/who influences you the most?
	e. What incident impacted you the most?
	f. What goals do you have in life? What do you need to do to achieve your goals?
	g. What gives you hope?
	h. Can you describe a difficult phase (or experience) in your life and how you went through it. What did you do? What did you learn about yourself as a result of this experience?
	i. Have you experienced any traumatic event/sudden changes in your life? How did you feel about the event/change? How did you deal with the trauma/change? When going through a rough time, who can you call for help or support?
5. Personal beliefs
Standard 3: preserving culture/religion	a. What cultural/religious practices do you follow in your family?
Standard 3: preserving culture/religion	b. How important are these cultural and religious practices to you?
Standard 3: preserving culture/religion	c. What does your culture/religion say about the role of the husband/wife/children?
6. Family relationships: Family dynamics
Definition of a child	a. In your opinion, what is the role and responsibilities of a child?
Standard 1: child participation	b. How do you communicate with your children? Can you describe with examples?
Standard 7: opportunities for fun/leisure	c. What fun or leisure activities do you have with your family? When was the last time you had this activity?
Standard 10: mitigating potential risk and threats	d. How do you handle conflicts in your family? Can you describe with examples?
Standard 10: mitigating potential risk and threats	e. If there is a crisis in the family, how does your family deal with it? How does your family make decisions?
Standard 10: mitigating potential risk and threats	f. If there is an emergency (for example, a medical emergency), how does your family deal with it?
Standard 1: child participation	g. How are decisions made in your family? Who makes it and how is it communicated to the family members?
7. Family relationships: Marital dynamics
Standard 5: nurturing positive values	a. How would you describe your relationship with your spouse?
Standard 5: nurturing positive values	b. How do you communicate with your spouse? Can you describe with examples?
Standard 5: nurturing positive values	c. In your opinion, what are the roles and responsibilities of a husband and a wife?
Standard 5: nurturing positive values	d. How do you handle conflicts or disagreements with your spouse? Can you describe with examples?
8. Parenting
All relevant minimum standards	a. What does it mean to be a parent?
Standard 2: safeguarding children	b. What do you think is the role of a parent? - what should a parent do and not do?
Standard 5: nurturing positive values	c. When your child does something wrong, how do you correct the behaviour? Please give examples.
Standard 5: nurturing positive values	d. When your child does something good, what do you do? Please give examples.
Standard 2: safeguarding children	e. What is most important to you when bringing up your child? What are some behaviours that you would consider unacceptable from your child?
Standard 4: promoting positive self identity	f. How is parenting a young child different from parenting a teenager? How is parenting a boy different from parenting a girl?
Standard 2: safeguarding children	g. Will parenting your own child be different from parenting a foster child? How so?
Standard 4: promoting positive self identity	h. What do you hope for your children?
9. Understanding foster care and motivation for fostering
	a. What do you understand about foster care?
	b. How is foster care different from adoption?
Minimum standards values statement	c. Why should a child be in foster care? Which child would you consider should be in foster care?
	d. What prompted you decide to apply to be foster parents?
Minimum standards values statement	e. Who have you discussed this with? What do the members of your household think about caring for a foster child in the family?
	f. How will fostering affect you and your family?
Minimum standards values statement	g. What concerns do you have about caring for a child who is not yours?
	h. Do you prefer to care for a foster child from a certain age group or gender? Are you willing to care for a child with a disability?

PART B: HOME INSPECTION CHECKLIST

Question	Yes	No	N/A
Is there a room with enough privacy and floor space for the child to sleep in?
Is there a separate bed for the child, with clean bedding and a mattress in good condition?
Does the child need to share the room with someone else? Additional information if yes: How many people will there be in the room? What are their ages and gender?
Does the home have electricity?
Are the electrical outlets safe?
Does the home have adequate clean water?
Does the home have adequate ventilation?
Does the home have adequate lighting?
Is there a bathroom with adequate facilities which are in working order?
Are there safe cooking facilities in the kitchen?
Does the home have a refrigerator?
Are there enough exits in the home for emergency evacuation?
Is the home generally clean?
Is there any foul smell inside the home?
Are any toxic materials kept in the home?
Does the home have a well-stocked first aid kit?
Does the home have adequate laundry and drying facilities?
Is the home used for purposes other than residential, such as for a business or as a storehouse?
Are there others besides the applicant’s family members staying in the home, either permanently or temporarily?
Is the home located in a safe neighbourhood?
Is the home easily accessible using public transportation?
Are there any medical facilities near the home?
Are there any educational facilities near the home?
Are there any recreational facilities near the home?

1. If so, are they kept in a safe place away from food items?

10.43 Annex 39: Trainers Report [Download]

Name (Father) Applicant 1: No. of training sessions completed:

Name (Mother) Applicant 2: No. of training sessions completed:

Topics	Rating	Remarks
Minimum Standards of Care	Able to understand content and apply knowledge acquired
Basic listening and communication skills	Able to understand content and apply knowledge acquired
First aid and guide to healthy living	Able to understand content and apply knowledge acquired
Keeping children safe	Able to understand content and apply knowledge acquired
Dealing with strong willed children	Able to understand content and apply knowledge acquired
Helping children with trauma	Able to understand content and apply knowledge acquired
Psychosocial development of a child, particularly related to teenagers	Able to understand content and apply knowledge acquired
Maintaining healthy parent-child relationships and developing positive parenting skills	Able to understand content and apply knowledge acquired
Any other comments:

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

• Able to understand content, however requires continuous training

• Keep in view pending assessment in other areas

• Unable to understand content or apply knowledge acquired

Trainer’s signature:

Trainer’s name:

Date:

10.44 Annex 40: Home Study Report [Download]

HOME STUDY REPORT INFORMATION PROCESS

HOME STUDY REPORT TEMPLATE

Part A: The Report

Date of application:

Date of intake interview:

Date of home assessment:

1. Demographic information

Name of applicant (Father)
Age
Legal status	⎕Refugee ⎕Asylum seeker ⎕ Undocumented
UNHCR card no./ Community card no.
Telephone contact no.
Ethnicity
Religion
Employment status	⎕Employed ⎕Self-employed ⎕Unemployed ⎕Homemaker
Place of work (if applicable)
Type of work (if applicable)
Average monthly income
Languages spoken
Years in Malaysia
Name of applicant (Mother)
Age
Legal status	⎕Refugee ⎕Asylum seeker ⎕ Undocumented
UNHCR card no./ Community card no.
Telephone contact no.
Ethnicity
Religion
Employment status	⎕Employed ⎕Self-employed ⎕Unemployed ⎕Homemaker
Place of work (if applicable)
Type of work (if applicable)
Average monthly income
Languages spoken
Years in Malaysia
No. of children (list names and ages)
No. of other members in the household (list names and relationship)
Current address
Rental per month
Brief description of the home

Applicants have been assessed as meeting the basic criteria to be foster parents?

• Yes

• No

1. History or background information

Area	Brief summary
Education
Employment
Family background
Reasons for leaving home country
Health

2. Home assessment findings

Areas of concern (home inspection checklist)	Description	Any improvements made or in the process of completion

3. Support system

Description of support system identified by applicants.

4. Personal and emotional well-being

Area and/or red flags	Opinion or observation	Justification (narrative examples)

5. Personal beliefs

Area and/or red flags	Opinion or observation	Justification (narrative examples)

6. Family relationships

Area and/or red flags	Opinion or observation	Justification (narrative examples)

7. Parenting styles or skills

Area and/or red flags	Opinion or observation	Justification (narrative examples)

8. Understanding foster care and motivations for fostering

Area and/or red flags	Opinion or observation	Justification (narrative examples)

9. Recommendation to be foster parents:

• Yes, fit to be foster parents

• Can be recommended, but requires working on specified areas

• Keep in view pending further training or assessment

• No, not ready to be foster parents

1. Resources needed and conditions to be fulfilled as foster parents:

• Resources: (please specify) ______________________________________________________________________________________________________________________________________

• Further training: (please specify) ______________________________________________________________________________________________________________________________________

• Others: (please specify) ______________________________________________________________________________________________________________________________________

Signature:

Name of Foster Parents Support Worker:

Date of report:

SELECTION COMMITTEE APPROVAL

Approved for admission into pool of foster parents
Resources to be provided or conditions to be imposed:

⎕Yes ⎕ No

Selection Committee Representative’s Signature:

Selection Committee Representative’s Name:

Date :

Part B : Information Collation Template (Excel document)

Intake Interview	Trainers Report	Selection Interview	List of Unresolved Red Flags after Selection Interview
Red Flags	Narrative/ Responses	Observations/ Opinions	Red Flags	Narrative/ Responses	Observations/ Opinions	Red Flags	Narrative/ Responses	Observations/ Opinions

10.45 Annex 41: Foster Care Agreement Form [Download]

This Foster Parents Agreement is to be negotiated between the organization and the foster parents prior to the initial placement, and whenever there are changes in the terms and conditions of the placement after subsequent reviews.

Foster Child Placement Agreement between:

The ‘Organization’ AND The ‘Foster Parents’

Representative: Name of Foster Parent 1:

Designation: ID. No.:

ID. No.: Type of ID:

Type of ID:

Name of Foster Parent 2:

ID. No.:

Type of ID:

We, the Foster Parents (as per the above named parties) agree to foster and provide temporary placement for the following child at the agreed timeframe determined by all parties:

Name of Child: ______________________________________________________

Case Referral No.: __________________________________________________

Placement period: From ____________________ to ____________________

This Agreement is effective from _____________ and will be in force until the end of the agreed placement period or until a new Agreement is signed.

General conditions of this Agreement

1. Foster care is a temporary arrangement between the Organization and the Foster Parents to provide a safe and nurturing home environment for the Foster Child.

2. This Agreement does not provide any legal relationship or interest between the Foster Parents and the Foster Child.

3. This Agreement is not an employment contract. The Organization is not employing the Foster Parents to care for the Foster Child although it may assist them by providing resources for the purpose.

4. This Agreement is the final and conclusive agreement between the Organization and the Foster Parents concerning the placement of the Foster Child. It supersedes all previous verbal or written agreements, promises, or statements. This Agreement can only be amended by writing a new Agreement, which must then be signed by the Organization Representative and both the Foster Parents.

The Organization agrees to:

1. Provide the following resources:

1. Rental : _________________________

2. Food : _________________________

3. Clothing : _________________________

4. Transportation : _________________________

5. Hygiene items : _________________________

6. School items : _________________________

7. Others : _________________________

1. Adhere to the standards prescribed by relevant Manuals and Handbooks.

2. Guide and brief the Foster Parents and the Foster Child throughout the foster care process, and provide regular updates as and when necessary.

3. Develop a care plan for the child and work together with the Foster Parents to achieve the placement goals.

4. Allow the Foster Parents to directly contact the Case Manager in case of an emergency.

5. Conduct a home visit at least once a month to maintain contact with the Foster Parents and the Foster Child.

6. Keep the Foster Parents informed on the child’s school progress, refugee status determination, medical treatment, and other issues that may help the Foster Parents provide better care and protection for the child.

7. Assist the Foster Parents with getting medical or mental health treatment for the child when necessary.

8. Provide the Foster Parents with continuous training and support services.

9. Attend to the Foster Parents’ needs and grievances related to foster care throughout the placement period.

10. Monitor and supervise all organization personnel to ensure the meeting of processes and ethical standards.

11. Give the Foster Parents at least _______ days of prior notice before terminating the foster care arrangement.

The Foster Parents agree to:

1. Accept the child for foster care placement and to provide care for the child in terms of food, housing, clothing, personal care items, recreation, and any additional needs based on the care plan and in the best interest of the child.

2. Provide care for the child based on the standards provided for in relevant Manuals and Handbooks.

3. Report or provide an update of the child to the Case Manager as required.

4. Allow the Case Manager to inspect your home during home visits.

5. Inform the Foster Parents Support Worker whenever there are changes in the family circumstances that may affect the foster care arrangement.

6. Consult the Case Manager before making life changing decisions for the child.

7. Attend continuous training sessions and the Foster Parents Support Group meeting to increase knowledge and skills to care for the child.

8. Assist the Case Manager in the implementation of the child’s care plan to meet the holistic needs of the child.

9. Keep the confidentiality of information about the child and to refer to the Case Manager before disclosing any information required. No information about the child should be disclosed to unauthorised persons.

10. Give at least _______ days of written notice, except in an emergency, to request the Organization to terminate the foster care arrangement.

I/We have read the terms and conditions above and agree to meet these requirements. I/We understand that this Agreement shall remain in force until amended by all parties signing a new Agreement or at the end of the foster care placement.

Signing this Agreement signifies that the Organization agrees to temporarily place this child in this home with these Foster Parents and that the Foster Parents agree to provide care and protection for this child during the placement period.

Signature of Organization Representative:

Name of Organization Representative:

Date:

Signature of Foster Parent 1:

Name of Foster Parent 1:

Date:

Signature of Foster Parent 2:

Name of Foster Parent 2:

Date:

List of personal belongings and items (for cash, note down the amount and for medications, state the type and amount of medicine) with the child on admission into the foster home:

No.	Item with Description	Amount or Quantity
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.

Signature of Foster Child:

Name of Foster Child:

Date:

Signature of Case Manager:

Name of Case Manager:

Date:

Signature of Foster Parents Representative:

Name of Foster Parents Representative:

Date:

10.46 Annex 42: Admission Appeal Form [Download]

Name of Appellant:

Address:

Telephone contact no.:

Email:

Complete this section if someone is assisting the appellant in making the appeal.

Name of person assisting:

Organization (if applicable):

Address:

Telephone contact no.:

Email:

Relationship to Appellant:

Type of application: ⎕ Admission to Case Management ⎕ Placement in foster care

Date of notice of Case Conference decision:

Why are you appealing? What is your desired outcome from the request for decision review?

What is the justification for your appeal? On what basis do you think the decision should be changed?

Signature of Appellant:

Date:

For Office Use

Date received:

Decision to be reviewed by:

REVIEW DECISION

Outcome of appeal:

Justification for final decision:

Signature of reviewer: Date:

10.47 Annex 43: Internal Monitoring and Evaluation Framework [Download]

Objective 1: To develop and implement a functioning alternative that is utilised to provide care and protection for UASC at risk of immigration detention. Hypothesis: ‘The community placement and case management services of the CPCM Programme lead to the increased safety, stability and permanency, and well-being of the UASC within Malaysia.’ Objective 2: To develop and implement a functioning alternative that meets international minimum standards and is in line with child protection policies and best practices. Hypothesis: ‘The community placement and case management services of the CPCM Programme is delivered in accordance with the principle of being in the child’s best interest, while meeting international minimum standards.’
Programme Goal 1- Safety	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child in out-of-home care is safe.	Every child is physically protected in a safe out-of-home care environment without threat or actual presence of abuse, maltreatment or neglect.	A risk and safety assessment is completed for each child within one week of referral or within 24 hours of referral if the child’s preliminary needs are assessed as urgent.	# of risk and safety assessment completed within required timeframe. # of risk and safety assessment not completed within required timeframe.	Successes and challenges in completing risk and safety assessments within the timeframe.	Client review and assessment form
		A child who is assessed as being in present danger within care arrangements is referred to safer care arrangements within 24 hours.	# of children assessed as being in present danger. # of these children successfully placed within safer care arrangements within the timeframe.	Successes and challenges in placing a child in safer care arrangements within the timeframe.	Intake assessment Heightened risk criteria Care plan
		A child that is assessed as being in immediate danger referred to safer care arrangements in 30 days	# of children assessed as being in immediate danger. # of these children successfully placed within safer care arrangements within the timeframe.	Successes and challenges in placing a child in safer care arrangements within the timeframe.	Intake assessment Heightened risk criteria Care plan
	Every child has the necessary skills to protect himself/herself.	Contingency and safety plans developed with the caregiver and the child.	# of children who have a contingency and safety plan in place.	Impact of safety plan on the child and caregiver.	6-month, 12- month client review and assessment form
		Protective factors developed and increased.	# of children who have a reported increase in identifiable protective factors within 6 months and 12 months of engagement with the Programme. (For each child – Number of protective factors before admission vs. Number of protective factors 6 months and 12 months later)	Protective factors identified.	Intake assessment 6-month, 12- month client review and assessment form
Programme Goal 2a -Stability	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has family links established.	A child’s family link that was lost with migration is restored.	Tracing and family reunification activities carried out where appropriate.	# of children where family reunification/tracing in the best interest of the child. # of children where tracing/family reunification initiated. # of children successfully reunited with family.	Successes and challenges in tracing and family reunification.	Intake Assessment Client review and assessment form
To ensure every child has an alternative placement of care established in Malaysia.	Every child is guided through the options of: a) kinship/care by a relative b) foster care arrangement, or c) independent living for older children. Alternative placement of care in Malaysia developed for each child.	All children have an alternative care assessment carried out on admission into the Programme.	# of alternative care assessments carried out # of children without a safe care arrangement : # of placement interventions developed within 2 weeks # of children in kinship care # of children in foster care # of children in independent living # of review of placement every two weeks # of reports of challenges/ problems with placement # of failed placement # of BIA’s conducted within 12 weeks. # of children report an increased feeling of stability in placement. # of care plans reviewed per month. # of children who report an increased feeling of stability in placement. # of changes in placement needed per child on average.	Successes and challenges in securing alternative care arrangements.
		All children without alternative care arrangements have a placement intervention plan developed, based on their needs within two weeks.
		All children in interim alternative care arrangements will have their situation monitored every 2 weeks until a best interest assessment has been conducted.
		All children in care arrangements have a best Interest assessment conducted within 12 weeks to determine the stability of care arrangements.
		All children in stable care arrangements have care plans reviewed once a month.
Programme Goal 2b - Permanency	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has some form of legal protection in Malaysia.	Every child has legal protection that prevents arrest and detention.	Every child has his/her legal status resolved.	# of children undocumented on intake. # of partner referrals, and interventions conducted within 20 days of admission. # of children on pathway for having their legal status resolved. # of children documented following relevant interventions.	Successes and challenges in resolving the legal status for a child.	Intake assessment Care plan Client review form
To ensure every child is working towards a durable solution or longer term outcomes.	Every child is prepared for longer term solutions in or out of Malaysia.	Every child has a durable solution plan developed – which includes a) resettlement b) repatriation c) local integration d) independent living on turning 18.	# of children on pathway for resettlement. # of children on pathway for repatriation. # of children on pathway for local integration. # of children on pathway for independent living. # of children with no durable solution plan developed. # of children with successful achievement of durable solutions.	Successes and challenges in developing durable solutions.	Intake assessment Care plan Client review form
Programme Goal 3a - Material Well-being	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure children have their basic needs and general wellbeing met	Every child has access to adequate food, water, clothing and other essential items.	Initial needs assessment which evaluates the child’s access to food, water and sanitary items is undertaken within one month of referral. Monthly support is provided in the form of material aid for a child who is assessed as requiring assistance to meet his/her basic needs.	# of children assessed as requiring material support. # of children receiving monthly material support. # of children reporting increased meeting of material needs	Successes and challenges in the provision of material aid.	Client assessment and review form Care plan review
Programme Goal 3b - Physical Health	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has improved access to adequate physical health services.	Every child has better access to physical health care services.	Every child’s health needs assessed during the initial needs assessment. Children assessed to have ongoing health issues, or who may need ongoing access to medications or treatment will have a health plan developed and will be assisted to have access to health intervention.	# of children requiring physical health intervention. # of children unable to access physical health intervention. # of children with improved access to physical health intervention. # of children with health issues resolved following intervention/referral.	Successes and challenges in accessing physical health services.	Client assessment and review form Care plan review
Programme Goal 3c – Mental Health	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has improved access to adequate mental health services.	Every child has better access to mental health care services.	Every child’s mental health needs assessed during initial needs assessment. Children assessed to have ongoing mental health issues, or who may need ongoing access to medications or treatment will have a mental health plan developed and will be assisted to have access to mental health intervention.	# of children requiring mental health intervention. # of children unable to access mental health intervention. # of children with improved access to mental health intervention. # of children reporting increased mental health and emotional stability.	Successes and challenges in accessing mental health services.	Client assessment and review form Care plan review
Programme Goal 3d - Education	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has improved access to adequate educational opportunities.	Every child has better access to educational services.	Every child’s education level/needs assessed during initial needs assessment. Every child referred to some form of formal/informal learning institution and other skills based learning services.	# of children requiring educational services. # of children unable to access educational services. # of children currently enrolled/accessing educational services following referral/intervention. # of children who dropped out of referred educational services.	Successes and challenges in accessing educational services.	Client assessment and review form Care plan review
Programme Goal 3e - Housing	Outcome	Indicator	Quantitative Outputs	Qualitative Information	Data Collection Method
To ensure every child has adequate housing.	Every child has access to adequate housing with proper sanitation, hygiene and safety.	Initial needs assessment on access to appropriate housing conducted one month of referral. Monthly support in the form of material aid for children assessed as requiring assistance to meet their housing needs.	# of children assessed as requiring housing support. # of children receiving monthly housing support. # of children reporting increased stability in meeting their housing needs.	Successes and challenges in the provision of housing aid.	Client assessment and review form Care plan review

1. How were challenges overcome?

2. Outcome of completed risk and safety assessments.

3. Outcome of safer care placements.

4. Outcomes of safer care placements.

5. Feedback on impact of protective factors from the child and other people in the child’s life.

6. Feedback from child and family on tracing/family reunification initiatives.

7. Outcomes from successful family reunification.

8. Challenges/problems with placement.

9. Reasons for changes in placement for stable cases.

10. Reasons for changes in placement for within the first three months of a case

11. Feedback from Best interest assessments

12. Outcomes of documentation following intervention – feedback from client.

13. Outcomes of lack of documentation - feedback from client.

14. Outcomes of preparation for durable solutions.

15. Feedback from clients on the provision of aid.

16. Feedback from client on intervention outcomes.

17. Review of services/ options.

18. Feedback from client on intervention outcomes.

19. Review of services/ options.

20. Feedback from client on intervention outcomes.

21. Review of educational services/options.

22. Feedback from client on the provision of aid.

10.48 Annex 44: Client Needs and Risks Intake Summary and Proposed Case Action Plan [Download]

DEMOGRAPHIC DETAILS OF CHILD (including contact information, child’s history and background information)	[insert photo* *of the child]
Case Reference No.:
Name of the child:
Date of birth/Year of birth:
Gender:
UNHCR Documentation (if any):
NGO/Community Card no.:
Address:
Telephone no.:
Ethnicity:
Country of origin/ Place of birth:
Religion:
Languages spoken:
CAREGIVER(S) INFORMATION AND CONTACT DETAILS
Name (1):
Address:
Telephone no.:
UNHCR no./ Community Card no.:
Relationship with child:
Name (2):
Address:
Telephone no.:
UNHCR no. /Community Card no.:
Relationship with child:
Background information on caregiver (s) if any:
CHILD SAFETY ASSESSMENT Main assessment point: What is the child’s safety status if returned to the community?
Yes, the child is safe.	No, the child is not safe.
Please give details.	The following safety risks have been identified:
Describe the child’s current living arrangement: e.g. Who does the child stay with? Is the child paying rent or any monies to the household? Does the child feel comfortable staying there?
SAFETY ACTION PLAN
Child Safety Plan Describe the safety plan here. Include the contingency plan for custody in situations where caregivers are arrested by authorities.
Safety referral made? Yes No
If yes, Child client is referred to: Child will be accompanied by: (give name and describe relationship e.g. mother)	If no, why not?
	Please explain:
CHILD HEALTH NEEDS ASSESSMENT Main assessment point: Does the child require a health referral?
Does the child have any diagnosed illness/ongoing health condition?
Yes (please specify below)	No Not known
Diagnosed illness: Current treatment (treatment location and type):
Does the child require a health referral?	No, a referral is not needed because:
HEALTH ACTION PLAN
Health referral made? Yes No If yes, Child client is referred to: Child will be accompanied by:	HEALTH REFERRAL NEEDED, BUT NOT MADE BECAUSE:
	Referral declined by child. Referral refused by caregiver.	Service unavailable. Non-urgent referral made.
	Explain:
Note: In cases of medical emergency, it is in the child’s best interest to receive life-saving care. If a caregiver or child refuses the referral, a supervisor must be contacted immediately and/or a referral made if the child’s life is at risk.
CHILD PSYCHOSOCIAL NEEDS ASSESSMENT Main assessment point: What is the child’s current emotional state and level of functioning?
Reporting of child’s emotional state/current behaviour: Emotional trauma from detention. Stopped going to school. Stopped leaving the house. Stopped playing with friends. Feels sad most of the time. Exhibits sleeping or eating changes. Other major changes or difficulties reported:	Describe the child’s emotional state: (describe expressed or observed emotional state of the child)
Is the child receiving psychosocial support/counselling? Yes No Not known Not needed
What is the caregiver’s understanding of the child’s current functioning? Explain, if possible	List the child’s/family’s strong points: (list the positive things that the child/family has)
PSYCHOSOCIAL ACTION PLAN
Provide emotional support.	Provide counselling with caregiver and/or other family members.
	Describe why this is needed and how it will be done:
LEGAL NEEDS ASSESSMENT AND ACTION PLAN Main Assessment point: What is the child’s current legal status
What documents do you have:? UNHCR Refugee card – Card no.: _______________________ UNHCR Asylum Seeker Card - Card no.: ________________ UNHCR Appointment card – Serial no.: _________________	Identity Document - ID Type and No: _________________ Passport – Issuing country and No: _________________ No Document
Have you been referred to any legal aid agency for legal services? Yes No	If yes, please provide information on the service provider, intervention and reason for referral:
FOR UNHCR PERSONS OF CONCERN: UNHCR referral made? Yes No If yes, Which unit is the child referred to? Reasons for referral: Child will be accompanied by:	If no, why not?
	Please explain:
FOR CHILDREN OF MIGRANT PARENTS or UNDOCUMENTED CHILDREN Has a referral to the embassy been made?: Yes No If yes, Please list which embassy and reasons for referral:	If no, why not?
	Please explain:
LEGAL NEEDS ACTION PLAN
Referral to legal aid provider for assessment/preparation.
	Describe why this is needed and how it will be done:
WELFARE NEEDS Main assessment point: Is the child’s basic welfare needs being met?
Does the child have a safe place to stay? Yes No Not known Does the child feel safe/comfortable staying there? Yes No Not known Is the child required to pay rent? Yes No Not known If yes, is the child able to pay rent on his/her own? Yes No Not known N/A Does the child have his/her own room? Yes No Not known Does the child have bedding? Yes No Not known Does the child’s room have adequate ventilation? Yes No Not known	Is there adequate sanitation in the home? Yes No Not known Is the overall housing environment clean – no water stagnation, rodents? Yes No Not known Is the child’s house clean and not overcrowded? Yes No Not known Does the child have adequate nutritious food to eat on a daily basis? Yes No Not known Does the child have other basic needs –sanitation items, clothes, shoes? Yes No Not known
Any other relevant basic needs identified:
WELFARE NEEDS ACTION PLAN
Food support provided. Rental support provided. Bedding provided. New placement/room acquired. Other basic items provided – clothing, sanitary items. Any other provision: __________________________________
	Describe why this is needed and how it will be done:
SPECIFIC TRAUMA/EXPLOITATION ASSESSMENT Main assessment point – What is the child’s current emotional state and level of functioning?
Has the child been arrested and detained? Yes No If yes, for how long was the child in detention? _________________________________________	Any related experience during detention that the child has shared:
Has the child experienced any specific incidences of violence/abuse in his/her home country and/or in Malaysia?	If yes, please briefly describe incidences:
Yes No
ACTION PLAN
Provide emotional support.	Provide counselling with caregiver and/or other family members.
	Describe why this is needed and how it will be done:
CHILD’s EDUCATION and EMPLOYMENT NEEDS Main assessment point - Is the child going to school or employed?
EDUCATION Is the child is going to school? Yes No If yes, which school?: If not schooling, has a referral to community school been made? Yes No	If no, why not?
	If no why not?
EMPLOYMENT Is the child working? Yes No	If yes, What type of work is it? Location of workplace:
ACTION PLAN
Visit to place of work to assess work conditions. Monitoring of work conditions. Referral to community/NGO school. Referral to language classes. Referral to vocational/skills based classes. Setting up of independent English classes.	Describe why this is needed and how it will be done:
CASE ACTION PLAN REVIEW AND FOLLOW- UP MEETING (to be filled in after discussion with the client)
This Assessment and Case Action Plan has been developed and agreed by:
Child/Client	Caregiver/Other relations	Case Manager
Are all relevant consent forms for referral signed?: Yes No
If not, explain why:
Follow up meeting is scheduled on: Date: Location:

Child’s caregivers cannot or will not protect/provide for the child.

Child has no caregiver/is living on his/her own.

Child has experienced abuse and the perpetrator lives with the child/can easily access the child at home.

Child is fearful of family members and does not want to return home.

Other reasons: (please identify)______________________________

Yes, a health referral is needed because:

Child complains of physical pain and injury.

Child has not received any health treatment since entering the country or since being released from detention.

Other reasons:

(Please explain)___________________________

Services already received from another agency.

Service not applicable.

Other reasons: (Please explain)

Provide education and counselling about coping mechanisms.

Assist the child with any problems identified
in the assessment above (going back to school, etc.).

Referral to relevant psychosocial support agency:

________________________________________

Referral to UNHCR for UNHCR POC’s.

Referral to embassies for migrant children

Provide education and counselling about coping mechanisms.

Assist the child with any problems identified
in the assessment above.

Referral to relevant psychosocial support agency:

________________________________________

CASE MANAGER		REVIEW BY CASE SUPERVISOR
Name:		Name:
Contact information (email and telephone no.):		Contact information (email and telephone no.):
Signature:		Signature:
Date:		Date:

---

15. Some suggestions for various debriefing techniques can be found here: https://onlineteachingandlearning.wikispaces.com/file/view/Processing+Effective+Debriefing+Tools.pdf.↩︎

16. Some suggestions for various debriefing techniques can be found here: https://onlineteachingandlearning.wikispaces.com/file/view/Processing+Effective+Debriefing+Tools.pdf.↩︎

17. A child is in present danger when there is immediate, significant, and clearly observable threat actively occurring in the present. Danger or safety threats include any real or risk of physical, sexual, verbal maltreatment, abuse or neglect.↩︎

18. A child is in imminent danger when there are conditions that are not immediately obvious or currently actively occurring but are out of control and likely to cause serious harm to a child in the near future. For imminent danger, the harm is likely in the near future (i.e. not exceeding 60 days) if no intervention is carried out.↩︎

19. Information for this tool was compiled from various sources including: ICRC Family Tracing forms for Liberia and Uganda (Available at: http://www.savethechildren.org.uk/sites/default/files/docs/FAMILY-TRACING.pdf); Field UNHCR Best Interests Assessment from the Handbook for the Implementation of UNHCR BID Guidelines (Available at: http://www.refworld.org/pdfid/4e4a57d02.pdf); UNHCR Guidelines on Determining the Best Interests of the Child (Available at: http://www.unhcr.org/4566b16b2.pdf); ICRC Inter-agency Guiding Principles on UASC (Available at: https://www.icrc.org/eng/assets/files/other/icrc_002_1011.pdf).↩︎

20. This checklist has been adapted from the Physical Health Checklist developed by RETHINK. Available at: http://www.mifellowship.org/sites/default/files/pdfs/1.%20Rethink%20Tools/1.1%20physical%20health%20check.pdf.↩︎

21. This template is adapted from the NYC Department of Youth and Community Development Case Management Standards Toolkit, 2011. Available at:

    http://www.nyc.gov/html/dycd/downloads/pdf/NYC_DYCD_Case_Management_Toolkit-2011.pdf.↩︎