View Information Collection Request (ICR) Package

OMB Control No: 0970-0509	ICR Reference No: 202308-0970-003
Status: Historical Active	Previous ICR Reference No: 202205-0970-004
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: Revision of a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/16/2023
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	09/30/2026	36 Months From Approved	12/31/2023
Responses	207,800	0	108,225
Time Burden (Hours)	17,406	0	38,454
Cost Burden (Dollars)	0	0	0

Abstract: The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the forms Mental Health Assessment Form (formerly, the Health Assessment Form), Public Health Investigation Form: Active TB and Public Health Investigation Form: Non-TB Illness (OMB #0970-0509, expiration 12/31/2023). Revisions are proposed to the currently approved forms as described in section A15. 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 the appropriate medical, mental health and dental services per the Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A). While in care, children meet with onsite mental health counselors on a regular basis. If a child is identified as potentially having a more serious mental health condition, they are referred to a psychiatrist, psychiatric nurse practitioner or physician’s assistant, licensed psychologist, or other licensed mental health provider (e.g., social worker). Children may be exposed to nationally reportable infectious diseases during the journey to the U.S., while in the custody of the Customs and Border Protection after crossing the border, or during their stay in ORR custody. Public health interventions such as quarantine, vaccination or lab testing may be initiated to reduce possible disease transmission. Following an exposure, children are assessed onsite by care provider program staff and if found to be symptomatic, referred to a healthcare provider for evaluation. ORR requires care providers to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Mental Health Assessment and Public Health Investigation Forms information collections to implement and maintain compliance with the Flores Settlement Agreement.

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:
	88 FR 35879	06/01/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 52172	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	207,800	108,225	99,575
Annual Time Burden (Hours)	17,406	38,454	-21,048
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 former Health Assessment Form used for medical and mental health evaluations has been updated to only capture mental health information collected during evaluations with a psychiatrist, psychiatric nurse practitioner or physician’s assistant, licensed psychologist, any other community based licensed mental health provider (e.g., social worker) and onsite clinicians at residential treatment centers in the ORR network, and renamed to the Mental Health Assessment Form. This change will simplify and streamline the data collection process for healthcare providers as the fields are tailored towards mental health evaluations. In addition, several changes/updates were made 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, 3) reformatting and building out several fields to clarify intent of current high-level specify fields, and 4) adding/revising the physical and mental status exams and diagnoses. These changes were made to ensure the healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner. On both Public Health Investigation forms, updates were made to the wording of several fields to clarify intent and unnecessary fields were removed to reduce burden. Lastly, an instructional letter was written for mental health professionals completing the Mental Health Assessment Form that explains the purpose and data collection guidelines (Attachment B). 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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