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OMB Control No: 0970-0466	ICR Reference No: 202410-0970-004
Status: Historical Active	Previous ICR Reference No: 202312-0970-002
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 with change	Conclusion Date: 10/08/2024
Retrieve Notice of Action (NOA)	Date Received in OIRA: 10/07/2024
Terms of Clearance: Approved consistent with the understanding that ACF will safeguard individual's privacy to the greatest extent possible as discussed with subject matter experts on 10/4/24.

	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. The following two Administration for Children and Families (ACF) Office of Refugee Resettlement (ORR) information collections capture health data on children in ORR care: • Medical Assessment Form and Dental Assessment Form • Mental Health Assessment Form and Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness. ORR has recently identified a specific need to share data collected on ORR’s health assessment forms that falls outside of the stated limitations with the Department of Homeland Security (DHS). The need to communicate with DHS occurs when a newly referred child arrives at an ORR facility ill or requires emergent/urgent healthcare services shortly after placement and ORR was not notified in advance. For DHS to investigate the event, ORR must share confidential and sensitive health information including the child’s alien number, name, signs/symptoms, diagnoses, and date of diagnosis. The goal of this data sharing effort is to identify areas of potential improvement in delivery of healthcare services and continuity of care for children transferred from DHS to HHS custody. Currently, there is specific language in the Supporting Statements describing limitations on data sharing that limits ORR’s ability to fulfill this need. ORR has discussed the need to update this language with OMB and as a result ORR published a notice in the Federal Register (89 FR 54829) on July 2, 2024 announcing a 30-day period for the public to comment on the proposed changes. No comments were received, and we are now submitting the updated Supporting Statement A for final review and approval.

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
Annual Number of Responses	619,000	619,000
Annual Time Burden (Hours)	160,815	160,815
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:

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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