Final Instrument for Generic Monitoring Form_12.19_mj 1.4.23 ln

OMB #: 0970-0558

Expiration Date: 11/30/2023

INTRODUCTION: The purpose of this information collection, Monitoring the Status of Required Licensure, is to monitor recipients’ progress in obtaining the required licensure to provide residential services to unaccompanied children. This information will be used to ensure that recipients that are not yet licensed to provide residential services become licensed by the appropriate state licensing agency in a timely manner. ORR will collect the below information from recipients on a bi-monthly basis and the response time should take no more than 30 minutes per program.

1. What is the status of your program’s license?

2. What steps has your program taken to obtain the required licensing?

3. What are the delays?

4. When was the application and required documentation submitted to the appropriate office?

5. Do you have an estimated date for when the license will be received?

6. If the required documentation was not submitted, why not?

7. If you have not started the process to obtain licensure, why not?

8. What type of licensure is required by your state to provide the funded services?

9. Please provide the name and contact information of your licensing representative.

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to monitor recipient’s progress as it relates to obtaining the required licensing to provide residential services to UC in ORR custody. Public reporting burden for this collection of information is estimated to average 30 mins per recipient per response, including the time for reviewing instructions, gathering, and maintaining the data needed, and reviewing the collection of information. This is a mandatory collection of information (6 U.S.C. § 279). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0558 and the expiration date is 11/30/2023. If you have any comments on this collection of information, please contact ucpolicy@acf.hhs.gov.

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