View Information Collection Request (ICR) Package

OMB Control No: 0970-0466	ICR Reference No: 202308-0970-002
Status: Historical Active	Previous ICR Reference No: 202205-0970-003
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Medical Assessment Form and Dental Assessment Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/26/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/08/2023
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2026	36 Months From Approved	12/31/2023
Responses	619,000	0	61,815
Time Burden (Hours)	160,815	0	33,950
Cost Burden (Dollars)	0	0	0

Abstract: The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the Medical Assessment Form (formerly, the Initial Medical Exam Form and Supplemental Tuberculosis Screening Form) and Dental Assessment Form (formerly, the Dental Exam Form) (OMB #0970-0466, expiration 12/31/2023). The ACF Office of Refugee Resettlement (ORR) places unaccompanied children in their custody in care provider programs until unification with a qualified sponsor. Care provider programs are required to ensure children receive appropriate medical, mental health and dental services. Per ORR requirements, each child must receive an initial medical exam (IME) within 2 business days of admission to an ORR care provider program or temporary influx care facility (ICF). The IME satisfies Flores requirements which require a “complete medical examination, including a screening for infectious disease. See Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A). The purposes of the IME are to assess general health, administer vaccinations in keeping with U.S. standards (also required by Flores), identify health conditions that require further attention, and detect contagious diseases of public health importance, such as influenza or tuberculosis. The IME is performed by a licensed health care provider and comprised of a complete medical history and physical exam, risk- and age-based laboratory screenings, tuberculosis screenings and immunizations. Children who are in ORR custody 60 to 90 days after admission must receive an initial dental exam, or sooner if directed by state licensing requirements. Children who are in ORR care for an extended length of time may also require routine medical and dental well-child evaluations. In addition, children may be referred to a medical or dental specialist by their healthcare provider for acute or chronic conditions that require additional evaluation, or they may need emergent/urgent care services. ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, immunizations, and treatments are documented and included in the child’s discharge packet at the time of unification with their sponsor. ORR requires the Medical Assessment and Dental Assessment information collections to implement and maintain compliance with the Flores Settlement Agreement.

Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores 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:
	88 FR 35883	06/01/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 52166	08/07/2023
Did the Agency receive public comments on this ICR? No

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	619,000	61,815	557,185
Annual Time Burden (Hours)	160,815	33,950	126,865
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The currently approved information collection includes an Initial Medical Exam Form and a Supplemental TB Screening Form. Data collection for all other medical evaluations is conducted on the Health Assessment Form under forms approved under OMB #0970-0509 . This new request merges the medical data from the three forms into a single Medical Assessment Form that will be used during all evaluations with a mid-level, or higher medical professional (e.g., medical doctor, nurse practitioner), including the IME. This change will simplify and streamline the data collection process for healthcare providers as the same form will be used for every medical assessment regardless of the reason for the visit. In addition, several changes were made to the Medical and Dental Assessment Forms including, 1) adding fields to the General Information section to capture information on translation services and purpose of visit, 2) enhancing the History and Physical Assessment section to obtain a more thorough health and social history, and 3) reformatting and building out several fields to clarify intent of current high-level specify fields. Other updates made solely to the Medical Assessment Form include the addition/revision of the physical and mental status exams, diagnoses, and lab testing requirements. These changes were made to ensure healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner. Adjustments were made to the lab testing requirements in accordance with the changes made to ORR’s IME requirements. Lastly, instructional letters have been written for each respondent completing an Assessment Form that explain the purpose and data collection guidelines for each form (Attachments B and C). Adjustments have been made to burden estimates where applicable and burden estimates have been broken out to display burden more clearly for each type of respondent and activity.

Annual Cost to Federal Government: $789,687

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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