Initial Medical Exam Form and Dental Exam Form

Forms and Documents

Document Name	Status
Form 1 Dental Exam Form Form	Unchanged
Form 1 Initial Medical Exam Form Form	Modified
NonSub Change Request_0466.docx Justification for No Material/Nonsubstantive Change	2022-05-09
SUPSTAT_HHS OMB 0970-0466_Final.docx Supporting Statement A	2020-09-28
Attachment A - Flores Agreement.doc Supplementary Document	2015-08-05

IC Document Collections

IC ID	Document Title	Status
217789	Dental Exam Form Form	Unchanged
217788	Initial Medical Exam Form Form	Modified

ICR Details

OMB Control No: 0970-0466	ICR Reference No: 202205-0970-003
Status: Received in OIRA	Previous ICR Reference No: 202009-0970-012
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Initial Medical Exam Form and Dental Exam Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 05/09/2022

	Requested	Previously Approved
Expiration Date	12/31/2023	12/31/2023
Responses	61,815	61,815
Time Burden (Hours)	33,950	33,950
Cost Burden (Dollars)	0	0

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Abstract: 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. Unaccompanied minors in ORR custody are placed in grantee-operated licensed care provider facilities that arrange for appropriate healthcare as directed by ORR. All children are required to receive a complete medical examination including screening for infectious diseases and immunizations recommended by the Centers for Disease Control and Prevention within 2 business days of admission into an ORR-funded licensed care provider facility. If children are still in ORR custody 60 to 90 days after admission, they are required to receive an initial dental exam, or sooner if directed by state licensing requirements. Additional required services include routine medical and dental care, family planning, and emergency health care. ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnosed conditions/illnesses, immunizations, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Initial Medical Exam and Dental Exam information collections to implement and maintain compliance with the Flores Settlement Agreement (Attachment A). The Initial Medical Exam is performed by a mid-level medical professional or higher and includes a psychosocial risk evaluation that is used to identify potential mental health concerns or symptoms. To capture these concerns and symptoms, disorder-based mental health diagnosis options were listed in the Behavioral and Mental Health Concerns category within the Diagnosis section of the current Initial Medical Exam Form. However, since the date of approval, an ORR Behavioral and Mental Health Team comprised of licensed mental health professionals was created and after careful consideration, the Team believes the current format may cause a child to be prematurely and inappropriately labeled with a mental health disorder. Per ORR guidelines, a child identified with a symptom-based diagnosis at the Initial Medical Exam would be referred to a specialist for evaluation and a disorder-based diagnosis which would be captured in the Health Assessment form (OMB #0970-0509). Therefore, ORR feels that it is in the best interest of the child to provide symptom-based mental health diagnoses in lieu of disorder-based diagnoses on the Initial Medical Exam Form.

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Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores Agreement
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 15477	03/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60801	09/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Dental Exam Form	1	Dental Exam Form
Initial Medical Exam Form	1, 1	Initial Medical Exam Form ,   Appendix A_Supplemental TB Screening Form

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ICR Summary of Burden

	Total Request	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	61,815	61,815	0	0	0	0
Annual Time Burden (Hours)	33,950	33,950	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:

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Annual Cost to Federal Government: $22,187

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

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Common Form ICR:  No

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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: 05/09/2022

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