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OMB Control No: 0970-0509	ICR Reference No: 202205-0970-004
Status: Historical Active	Previous ICR Reference No: 202009-0970-013
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/16/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 05/09/2022
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	12/31/2023	12/31/2023
Responses	108,225	0	108,225
Time Burden (Hours)	38,454	0	38,454
Cost Burden (Dollars)	0	0	0

Abstract: Pursuant to Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK (C.D. Cal. 1996), the Administration for Children and Families’ Office of Refugee Resettlement (ORR), on behalf of the Department of Health and Human Services (DHHS), is directed to provide unaccompanied children in their custody with medical, mental health, and dental care until reunification with a qualified sponsor. Unaccompanied minors in ORR custody are placed in grantee-operated licensed care provider facilities that arrange for appropriate emergent, routine and as-needed healthcare as directed by ORR, including “sick visits”, follow-up immunizations, urgent healthcare, and family planning services. Initial medical and dental and routine dental care are also required services for minors in ORR custody (OMB #0970-0466). ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnosed conditions/illnesses, immunizations, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Health Assessment and Public Health Investigation information collections to implement and maintain compliance with the Flores Settlement Agreement. To capture behavioral and mental health concerns and symptoms during these evaluations, disorder-based mental health diagnosis options were listed in the Behavioral and Mental Health Concerns category within the Diagnosis section of the current Health Assessment Form. However, since the date of approval, an ORR Behavioral and Mental Health Team comprised of licensed mental health professionals was created and after careful consideration, the Team believes the current format may cause a child to be prematurely and inappropriately labeled with a mental health disorder if the child is first evaluated by a non-mental health provider. Per ORR guidelines, a child identified with a symptom-based diagnosis during an evaluation with a healthcare provider would be referred to a specialist for evaluation and a disorder-based diagnosis. Therefore, ORR feels that it is in the best interest of the child to provide symptom-based mental health diagnoses as well as disorder-based diagnoses on the Health Assessment Form.

Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores Settlement Agreement

Citations for New Statutory Requirements: None

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 15476	03/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60802	09/28/2020
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved
Annual Number of Responses	108,225	108,225
Annual Time Burden (Hours)	38,454	38,454
Annual Cost Burden (Dollars)	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: In the previously approved information collection, the annual burden estimate did not include the time required by healthcare providers to complete the Health Assessment form, as it was assumed this information was already collected by the provider and did not impose additional burden. In order to account for the time needed for healthcare providers to fill out the ORR-developed Health Assessment form, however, ORR has since increased the burden estimate for this request.

Annual Cost to Federal Government: $18,027

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

Agency Contact: Molly Buck 202 205-4724 mary.buck@acf.hhs.gov

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