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:
0970-0509
ICR Reference No:
202312-0970-003
Status:
Historical Active
Previous ICR Reference No:
202309-0970-005
Agency/Subagency:
HHS/ACF
Agency Tracking No:
ORR
Title:
Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness
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
09/30/2026
09/30/2026
09/30/2026
Responses
207,800
0
207,800
Time Burden (Hours)
17,406
0
17,406
Cost Burden (Dollars)
0
0
0
Abstract:
The Mental Health Assessment Form was approved by OMB on September 16, 2023, as part of the Mental Health Asessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness Form information collection. The purpose of the Mental Health Assessment is to collect standardized health information on unaccompanied children during evaluations with mental health providers. In November 2023, ORR hired a Reproductive Health specialist who reviewed the Mental Health Assessment Form and recommended changes to the reproductive health history section. ORR believes these changes will aid mental health 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,
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
Number of Information Collection (IC) in this ICR:
6
IC Title
Form No.
Form Name
Mental Health Assessment Form - Recordkeeping Time
1
Mental Health Assessment Form
Mental Health Assessment Form - Reporting Time
1
Mental Health Assessment Form
Public Health Investigation Form: Active TB - Recordkeeping Time
1
Public Health Investigation Form: Active TB
Public Health Investigation Form: Active TB - Reporting Time
1
Public Health Investigation Form: Active TB
Public Health Investigation Form: Non-TB Illness - Recordkeeping Time
1
Public Health Investigation Form: Non-TB Illness
Public Health Investigation Form: Non-TB Illness - Reporting Time
1
Public Health Investigation Form: Non-TB Illness
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
207,800
207,800
0
0
0
0
Annual Time Burden (Hours)
17,406
17,406
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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