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. In November 2023, ORR hired a
Reproductive Health specialist who reviewed the Medical Assessment
Form and recommended changes to the reproductive health history
section and genito-urinary/reproductive diagnosis fields. ORR
believes these changes will aid healthcare providers in performing
a thorough assessment and creating an informed healthcare plan. ORR
would like to: • replace the field “if unknown, months since LMP"
with 2 options, “Approximate” and “Exact” in the last menstrual
period (LMP) field, • rename the “Current contraceptive use” field
to “Contraceptive use” and add a specify field with examples, •
replace the field “Pregnancy: Gravida ___ Parity ___; location
& age of child(ren):” with “Pregnancy history” and add discrete
options to capture the number of each pregnancy outcome (e.g.,
vaginal deliveries, ectopic pregnancies), • add a new free text
field called “Pregnancy/postpartum complications”, and • update
several diagnoses under the Genito-urinary/Reproductive category in
the Diagnosis and Plan section
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
NonSub Change Request_Medical Assessment Form_0970-0466.docx
Dental Assessment Form - Recordkeeping Time