Medical Assessment Form and
Dental Assessment Form
Revision of a currently approved collection
No
Regular
08/08/2023
Requested
Previously Approved
36 Months From Approved
12/31/2023
619,000
61,815
160,815
33,950
0
0
The ACF Office of Refugee Resettlement
(ORR) places unaccompanied children in their custody in care
provider programs until unification with a qualified sponsor. Care
provider programs are required to ensure children receive
appropriate medical, mental health and dental services. Per ORR
requirements, each child must receive an initial medical exam (IME)
within 2 business days of admission to an ORR care provider program
or temporary influx care facility (ICF). The IME satisfies Flores
requirements which require a “complete medical examination,
including a screening for infectious disease. See Flores Settlement
Agreement, Exhibit 1(A)(2) (Attachment A). The purposes of the IME
are to assess general health, administer vaccinations in keeping
with U.S. standards (also required by Flores), identify health
conditions that require further attention, and detect contagious
diseases of public health importance, such as influenza or
tuberculosis. The IME is performed by a licensed health care
provider and comprised of a complete medical history and physical
exam, risk- and age-based laboratory screenings, tuberculosis
screenings and immunizations. Children who are in ORR custody 60 to
90 days after admission must receive an initial dental exam, or
sooner if directed by state licensing requirements. Children who
are in ORR care for an extended length of time may also require
routine medical and dental well-child evaluations. In addition,
children may be referred to a medical or dental specialist by their
healthcare provider for acute or chronic conditions that require
additional evaluation, or they may need emergent/urgent care
services. ORR requires grantees to maintain records on each child
to ensure that health-related evaluations, diagnoses, lab results,
immunizations, and treatments are documented and included in the
child’s discharge packet at the time of unification with their
sponsor. ORR requires the Medical Assessment and Dental Assessment
information collections to implement and maintain compliance with
the Flores Settlement Agreement.
The currently approved
information collection includes an Initial Medical Exam Form and a
Supplemental TB Screening Form. Data collection for all other
medical evaluations is conducted on the Health Assessment Form
under forms approved under OMB #0970-0509 . This new request merges
the medical data from the three forms into a single Medical
Assessment Form that will be used during all evaluations with a
mid-level, or higher medical professional (e.g., medical doctor,
nurse practitioner), including the IME. This change will simplify
and streamline the data collection process for healthcare providers
as the same form will be used for every medical assessment
regardless of the reason for the visit. In addition, several
changes were made to the Medical and Dental Assessment Forms
including, 1) adding fields to the General Information section to
capture information on translation services and purpose of visit,
2) enhancing the History and Physical Assessment section to obtain
a more thorough health and social history, and 3) reformatting and
building out several fields to clarify intent of current high-level
specify fields. Other updates made solely to the Medical Assessment
Form include the addition/revision of the physical and mental
status exams, diagnoses, and lab testing requirements. These
changes were made to ensure healthcare providers are performing
complete physical and mental health exams and documenting diagnoses
in a standardized manner. Adjustments were made to the lab testing
requirements in accordance with the changes made to ORR’s IME
requirements. Lastly, instructional letters have been written for
each respondent completing an Assessment Form that explain the
purpose and data collection guidelines for each form (Attachments B
and C). Adjustments have been made to burden estimates where
applicable and burden estimates have been broken out to display
burden more clearly for each type of respondent and activity.
$789,687
No
Yes
Yes
No
No
No
Yes
Molly Buck 202 205-4724
mary.buck@acf.hhs.gov
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:
(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;
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.
Form 1 Dental Assessment Form - Recordkeeping Time
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx
Dental Assessment Form - Recordkeeping Time