ATTACHMENT B


SECOND SETTLEMENT AGREEMENT COMPLIANCE FORM

Name of Facility: ___________________________________ Date: ______________________

Reporting Period: ____________________ to _______________________

The following information is submitted pursuant to Paragraph 28 of the Second Settlement Agreement entered in United States v. Youth Services International, Inc. Defined terms herein have the meanings given in the Second Settlement Agreement.

1. Resident Tracking Form (copy for each resident who is deaf or hard of hearing)

Resident Name: ____________________________________________________

Resident #: ________________________________________________________

Date of First Custody: _______________________________________________

Languages Used: ___________________________________________________

Responsible YSI staff: 1. _____________________________________________

                                     2. _____________________________________________

                                     3. _____________________________________________

                                     4. _____________________________________________

Movement To Other Facilities

Departure Date To Which Facility? Return Date
     
     
     
     
     
     
     
     
     
     
     
     
     

Release Date: ____________________________________________________

II. Provision of Auxiliary Aids and Services

Please complete this chart accurately, stating the date of any request for auxiliary aids and services, the name of the person making such a request, the nature of the request, the facility’s determination regarding whether to provide the requested auxiliary aid or service and the reason for the determination, and the date on which such auxiliary aid or service was provided, if applicable. Please attach all documents related to any such request.

Request
Date
Name of
Requesting
Party
Nature of Request Determination and Reasons Date Aid or
Service
Provided
         
         
         
         
         
         
         
         
         


III. Technology

A. Telephones and Related Equipment

  Number of Items Required Date Items Installed or Provided
TTYs    
Volume control telephones    
Storage and availability of
telephone equipment
Status: Where are Accessible Phones stored?
Are all Accessible Phonesin good working order?
Answer for each Item.

B. Visual Alarms

  Number of Items Required Date Items Installed or Provided
Common-use areas    
Resident’s rooms    

C. Captioning and Decoders

  Number of Items Required Date Items Installed
Closed captioning decoders    
Televisions with captioning
capability
   
Availability of Television
Equipment
Status: Are all Decoders and Televisions in good working order? Answer for each Item.

IV. ADA Training

  Date of ADA Training
Administrative Personnel  
Admissions Personnel  
Supervisory Personnel  
Case Managers  
Clinical Staff  
Other Staff  

Persons in attendance at ADA Training Sessions: (continue list on back if necessary)
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________
___________________________________ ____________________________________

I certify that all information contained herein is truthful and accurate.

ADA COORDINATOR:

________________________________________________

DATE:

________________________________________________


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