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

ADA COORDINATOR:

________________________________________________

DATE:

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