View Information Collection Request (ICR) Package
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Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.
View ICR - OIRA Conclusion
OMB Control No:
0970-0466
ICR Reference No:
202312-0970-002
Status:
Historical Active
Previous ICR Reference No:
202308-0970-002
Agency/Subagency:
HHS/ACF
Agency Tracking No:
ORR
Title:
Medical Assessment Form and Dental Assessment Form
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:
12/08/2023
Retrieve Notice of Action (NOA)
Date Received in OIRA:
12/06/2023
Terms of Clearance:
Inventory as of this Action
Requested
Previously Approved
Expiration Date
10/31/2026
10/31/2026
10/31/2026
Responses
619,000
0
619,000
Time Burden (Hours)
160,815
0
160,815
Cost Burden (Dollars)
0
0
0
Abstract:
The Medical Assessment Form was approved by OMB on October 26, 2023, as part of the Medical Assessment Form and Dental Assessment Form information collection. The purpose of the Medical Assessment Form is to collect standardized health information on unaccompanied children during evaluations with generalist medical providers, pediatricians, and other medical specialty providers. In November 2023, ORR hired a Reproductive Health specialist who reviewed the Medical Assessment Form and recommended changes to the reproductive health history section and genito-urinary/reproductive diagnosis fields. ORR believes these changes will aid healthcare providers in performing a thorough assessment and creating an informed healthcare plan. ORR would like to: • replace the field “if unknown, months since LMP" with 2 options, “Approximate” and “Exact” in the last menstrual period (LMP) field, • rename the “Current contraceptive use” field to “Contraceptive use” and add a specify field with examples, • replace the field “Pregnancy: Gravida ___ Parity ___; location & age of child(ren):” with “Pregnancy history” and add discrete options to capture the number of each pregnancy outcome (e.g., vaginal deliveries, ectopic pregnancies), • add a new free text field called “Pregnancy/postpartum complications”, and • update several diagnoses under the Genito-urinary/Reproductive category in the Diagnosis and Plan section
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
Number of Information Collection (IC) in this ICR:
6
IC Title
Form No.
Form Name
Dental Assessment Form - Recordkeeping Time
1
Dental Assessment Form
Dental Assessment Form - Reporting Time
1
Dental Assessment Form
Medical Assessment Form - Recordkeeping Time (completed by a medical professional)
1
Medical Assessment Form
Medical Assessment Form - Recordkeeping Time (information obtained via health records)
1
Medical Assessment Form
Medical Assessment Form - Reporting Time for Medical Specialist, General
1
Medical Assessment Form
Medical Assessment Form - Reporting Time for Pediatricians, General
1
Medical Assessment Form
ICR Summary of Burden
Total Approved
Previously Approved
Change Due to New Statute
Change Due to Agency Discretion
Change Due to Adjustment in Estimate
Change Due to Potential Violation of the PRA
Annual Number of Responses
619,000
619,000
0
0
0
0
Annual Time Burden (Hours)
160,815
160,815
0
0
0
0
Annual Cost Burden (Dollars)
0
0
0
0
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:
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
Common Form ICR:
No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
(a) It is necessary for the proper performance of agency functions;
(b) It avoids unnecessary duplication;
(c) It reduces burden on small entities;
(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
(f) It indicates the retention periods for recordkeeping requirements;
(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
(i) Why the information is being collected;
(ii) Use of information;
(iii) Burden estimate;
(iv) Nature of response (voluntary, required for a benefit, or mandatory);
(v) Nature and extent of confidentiality; and
(vi) Need to display currently valid OMB control number;
(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
(i) It uses effective and efficient statistical survey methodology (if applicable); and
(j) It makes appropriate use of information technology.
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
Certification Date:
12/06/2023
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