SUPSTAT_HHS ORR-0276_Final_3252019

THE SUPPORTING STATEMENT

0970-0466

A. Justification

1. Circumstances Making the Collection of Information Necessary

Pursuant to Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK (C.D. Cal. 1996), the Administration for Children and Families’ Office of Refugee Resettlement (ORR), on behalf of the Department of Health and Human Services (DHHS), is directed to provide unaccompanied children in their custody with medical, mental, and dental care until reunification with a qualified sponsor. Upon admission into a licensed care provider program, all children are required to receive a complete medical examination including screening for infectious diseases and immunizations recommended by the U.S. Public Health Service (PHS), the Center for Disease Control and Prevention. If children are still in ORR custody 70 to 90 days after admission, they are required to receive an initial dental exam. Additional required services include routine medical and dental care, family planning, and emergency health care.

ORR requires care provider programs to maintain records on each child to ensure that health-related evaluations, diagnosed conditions/illnesses, immunizations, and treatments are documented, monitored, and included in the child’s discharge packet at the time of reunification. ORR requires the Initial Medical Exam and Initial Dental Exam information collections to implement and maintain compliance with the Flores Settlement Agreement (Attachment A).

2. Purpose and Use of the Information Collection

The purpose of the information collections is to collect health information on unaccompanied children at the time of admission for the medical exam and 70-90 days after admission for the initial dental exam in a standardized manner and record all findings in an electronic data repository in order to identify and track illnesses and conditions that require monitoring, control, and follow-up. The forms are to be used as worksheets by medical professionals to compile information that would otherwise have been collected during the initial medical or dental exam and to submit to care provider program staff at the conclusion of the exam. Care provider program staff will then transcribe the data into an electronic version of the form that resides in ORR’s secure data repository known as the “UAC Portal”.

Tuberculosis (TB) screening is an intrinsic part of the initial medical exam, however, the supplemental form for recording results was created because care provider program staff may be required to take children to the health department for screening if the clinician performing the initial medical exam lacks onsite testing or is unable to perform the testing in the stipulated timeframe.

Based on the experiences over the past three years, ORR has determined there is a need to expand collection of documentation from the immunization record alone to the immunization record, lab results, imaging study reports, and office notes. These documents are necessary in order for ORR medical staff to approve requested additional diagnostic work-up, conduct surveillance for potentially reportable infectious diseases, provide oversight in medically complex cases, and confirm correct interpretation of lab/imaging data. Since minors are often transferred among ORR programs or may be discharged and re-admitted to ORR custody several times, storage of these documents on the UAC Portal will provide a central location for the minor’s health information. The addition of these data collection items is accounted for in the burden estimates provided in A12.

3. Use of Improved Information Technology and Burden Reduction

Care provider program staff will enter data from the Initial Medical and Dental Exam forms into the UAC Portal and upload the original form to the child’s record. Fields in the UAC Portal are designed to reduce data entry time and errors by utilizing dropdowns, business requirements, and system logic. The UAC Portal will create and send automated notifications on significant events (e.g., illnesses and conditions of public health concern) to the ORR Medical Team. Data from the forms will be accessible to the ORR Medical Team and, in the event of a transfer, the medical staff at the new care provider programs in order to ensure continuity of care.

4. Efforts to Identify Duplication and Use of Similar Information

ORR is the only agency, via grantees, that performs full initial medical and dental exams on unaccompanied children. There is currently no standardized tool used by care provider programs to collect information gathered during the initial medical and dental exams.

5. Impact on Small Businesses or Other Small Entities

The proposed information collection request does not impact small businesses or other small entities. These information collections primarily affect the operations of the federal government, particularly, ORR’s management of the care and custody of unaccompanied children.

6. Consequences of Collecting the Information Less Frequently

ORR mandates that this data collection occur a single time as part of the admission process. The initial medical exam is performed within 48 hours of admission (excluding weekends and holidays); the initial dental exam is performed when a child has been in custody from 70 to 90 days (dependent on state codes where program is located). Performing the data collection less frequently would prohibit ORR from tracking, monitoring, and advising on medical and dental health issues in a timely manner and consequently, cause ORR to be in violation of the Flores Settlement Agreement.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

This request fully complies with the regulation 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

The 60-day Federal Register notice was published April 17, 2015 with page numbers 21245 -21246, Volume 80, No. 74 (Attachment B). No comments were received.

ORR consulted with two subject matter experts on migrant screening from the Centers for Centers for Disease Control and Prevention (CDC) and the American Academy of Pediatrics (AAP) in fiscal year 2015 to determine the appropriate fields to include, process flow, reporting format, and clarity of intent. Name and contact information is as follows:

1. Steve Benoit, MD

Medical Officer

Immigrant, Migrant, and Refugee Health

Division of Global Migration and Quarantine

CDC

Email: Bvy8@cdc.gov

Office phone: 404-639-5013, mobile phone: 404-852-4252

2. Janine Young, MD

Medical Director, Denver Health Refugee Clinic

Assistant Professor, Dept. of General Pediatrics

Denver Health and Hospitals

University of Colorado School of Medicine

Lowry Family Health Center

AAP member

Email: janine.young@dhha.org

Office phone: 303-602-4558, mobile phone: 720-281-8934

9. Explanation of Any Payment or Gift to Respondents

No monetary incentives or gifts are provided to respondent.

10. Assurance of Confidentiality Provided to Respondents

HHS requires that personally identifiable information is protected and will be redacted from any information released to the public. All personally identifiable information will not be included in any data or report issued publicly. ORR’s database that is used to collect and store information is also kept securely and in accordance with HHS security requirements.

11. Justification for Sensitive Questions

ORR collects sensitive health information on medical, reproductive, physical, sexual and substance abuse history, current symptoms, mental health status, lab results and diagnoses in order to monitor, counsel, and treat children as directed by the Flores Agreement. Recorded information becomes part of the child’s health record and is viewable only to care provider program staff who are/were responsible for the child, ORR field-based program managers, and ORR staff at headquarters.

12. Estimates of Annualized Burden Hours and Costs

Estimates used to calculate burden are based on the following factors:

• The number of times these data are collected is dependent upon the number of unaccompanied children crossing over the U.S. border on an annual basis. Based on the average number of children entering the U.S. between 2011 and 2014, ORR estimates that the number of children will be approximately 40,525 annually.

• Since fiscal year 2014, there have been approximately 150 ORR care provider programs. This number is expected to remain relatively constant.

• All children receive an initial medical exam, including screening for TB, within 48 hours of admission (excluding weekends and holidays).

• Children receive an initial dental exam if they are in ORR custody 70 to 90 days of admission, depending on state regulations where the care provider program is located. Based on the average number of children receiving an initial dental exam between 2011 and 2014, approximately 10% of children referred to ORR are still in custody 70-90 days post-admission.

• Based on pretesting for the additional information collection for the Initial Medical Exam forms, the average completion time was determined to be 13 minutes. Therefore, the opportunity costs burden for the Initial Medical Exam information collection has been increased by 3 minutes to account for the additional request. The opportunity costs for the Initial Dental Exam information collection remained at 5 minutes..

• Recordkeeping, to include scanning and saving documents and uploading to UAC Portal, should take approximately 5 minutes.

• Each care provider program typically has at least one Medical Coordinator who will accompany children to the initial exams and enter the data into the Portal. The average hourly rate paid by ORR-funded programs for a Medical Coordinator is $16.83/hour.

Estimated Opportunity Costs for Respondents:

Instrument	Number of Respondents	Number of Responses per Respondent	Average Burden Hours per Response	Total Burden Hours	Cost of burden per hour	Annual cost of burden
Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form)	150	297	0.22	9,801	$16.83	$164,951
Initial Dental Exam Form	150	30	0.08	360	$16.83	$6,059
Estimated Total Annual Burden				12,389		$171,010

Estimated Recordkeeping Costs for Respondents:

Instrument	Number of Respondents	Number of Responses per Respondent	Average Burden Hours per Response	Total Burden Hours	Cost of burden per hour	Annual cost of burden
Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form)	150	297	0.08	3,564	$16.83	$59,982
Initial Dental Exam Form	150	30	0.08	360	$16.83	$6,059
Estimated Total Annual Burden				3,924		$66,041

The estimated total cost for respondents to collect the information is $237,051.

13. Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers

There is no total annual cost burden to respondents or record keepers other than their time.

14. Annualized Cost to the Federal Government

The annual estimated cost for creating and maintaining the forms, performing data analysis, and conducting quality control is approximately $3,268 over three years. The forms were developed by an epidemiologist (GS-12) with an hourly rate of $40 who spent approximately 160 hours building the forms, making edits, and working with information technologists to design the electronic version for the UAC Portal. Therefore, it was estimated that creating the forms cost approximately $6,400. After the forms are implemented, two epidemiologists based at the ORR headquarters in Washington DC will each spend approximately 40 hours a year reviewing and analyzing data acquired from the forms. Based on the U.S. Department of Labor’s Bureau of Labor Statistics website (http://www.bls.gov/oes/current/oes191041.htm), the average hourly salary for an epidemiologist in the DC area is $42.56. Therefore, the annual estimated cost for reviewing and analyzing data in the UAC Portal is approximately $3,405.00.

The annual estimated cost for building and maintaining both forms in the UAC Portal is $20,000. The initial cost to build the forms was approximately $40,000. The anticipated cost to maintain the forms in the UAC Portal, including fixing system glitches and updating fields, is expected to be approximately $10,000 a year for the next three years.

The total estimated annual cost to the federal government is $23,268 for the next three years.

15. Explanation for Program Changes or Adjustments

Minor modifications were made to the collections in order to capture critical information regarding suspect cases of potentially reportable infectious diseases (e.g., active tuberculosis). New requested information includes lab tests, interventions (e.g., quarantine/isolation, postponement of intakes), and exposures. In addition, new diagnosis options were added to better standardize reporting of the most common diagnoses.

16. Plans for Tabulation and Publication and Project Time Schedule

The results of these information collections will not be published. Portions of the data included in the information collections could be included in public reports, but the purpose of the information collections is not to publish the direct results. These information collections are ongoing.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

ORR intends to display the expiration date for OMB approval of the information collections for both instruments.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

ORR does not request any exception to Certification for the Paperwork Reduction Act.

B. Statistical Methods (used for collection of information employing statistical methods)

1. Respondent Universe and Sampling Methods

Not applicable.

2. Procedures for the Collection of Information

Not applicable.

3. Methods to Maximize Response Rates and Deal with Nonresponse

Not applicable.

4. Test of Procedures or Methods to be Undertaken

Not applicable.

5. Individuals Consulted on Statistical Aspects and Individuals Collecting and/or Analyzing Data

Not applicable.

8