Supporting Statement A_Mental Health Assessment Form and Public Health Investigation Forms_fnl

Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness

OMB Information Collection Request

0970 - 0509

Supporting Statement Part A - Justification

August 2023

Submitted By:

Office of Refugee Resettlement

Administration for Children and Families

U.S. Department of Health and Human Services

Summary

The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the forms Mental Health Assessment Form (formerly, the Health Assessment Form), Public Health Investigation Form: Active TB and Public Health Investigation Form: Non-TB Illness (OMB #0970-0509, expiration 12/31/2023). Revisions are proposed to the currently approved forms as described in section A15.

1. Circumstances Making the Collection of Information Necessary

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 the appropriate medical, mental health and dental services per the Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A).

While in care, children meet with onsite mental health counselors on a regular basis. If a child is identified as potentially having a more serious mental health condition, they are referred to a psychiatrist, psychiatric nurse practitioner or physician’s assistant, licensed psychologist, or other licensed mental health provider (e.g., social worker).

Children may be exposed to nationally reportable infectious diseases during the journey to the U.S., while in the custody of the Customs and Border Protection after crossing the border, or during their stay in ORR custody. Public health interventions such as quarantine, vaccination or lab testing may be initiated to reduce possible disease transmission. Following an exposure, children are assessed onsite by care provider program staff and if found to be symptomatic, referred to a healthcare provider for evaluation.

ORR requires care providers to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Mental Health Assessment and Public Health Investigation Forms information collections to implement and maintain compliance with the Flores Settlement Agreement.

2. Purpose and Use of the Information Collection

The purpose of the Mental Health Assessment and Public Health Investigation Forms is to collect standardized health information on unaccompanied children during evaluations with mental health providers and care providers, respectively. Data collection for medical and dental visits, however, is conducted under a separate OMB-approved information collection: Medical Assessment Form and Dental Assessment Form (OMB #0970-0466¹).

The forms are to be used as worksheets for mental health providers and care providers to compile information that would otherwise have been collected during their evaluation. Once completed, the forms are given to care provider staff for data entry into ORR’s secure, electronic record system. Data is used by ORR to monitor the health of unaccompanied children while in care, for case management of identified illnesses/conditions, and to ensure care provider program compliance with ORR requirements. ORR also requires documentation of all health-related services rendered (e.g., immunization records, lab results, imaging study reports, office notes) to provide oversight on complex/fragile cases, authorize additional diagnostic work-up and procedures, and verify data entered in ORR’s electronic record system. The collection of this information in a central location allows for continuity of care for transferred and readmitted children.

3. Use of Improved Information Technology and Burden Reduction

Currently, care provider program staff enter data from the forms into the “UC Portal” and upload the original forms and related documentation to the child’s electronic record. Fields in the UC Portal are designed to reduce data entry time and errors by utilizing dropdowns, checkbox options, business requirements, and system logic. The UC Portal also generates automated notifications to ORR on significant events (e.g., admissions to out-of-network residential treatment centers). Data from the forms will be accessible to ORR and, in the event of a transfer, the new care provider program to ensure continuity of care.

ORR plans to procure a new secure electronic record system for capturing medical, mental health, dental and public health information in 2024. The new Mental Health Assessment Form and the Public Health Investigation Forms: Active TB and Non-TB Illness Forms will be replicated, and historic data stored in the UC Portal will be migrated to the new system. In addition, the new system will collate and display critical health information (e.g., medications, allergies, pending health appointments) on the child’s summary page for ease of tracking and reference.

4. Efforts to Identify Duplication and Use of Similar Information

The information being collected by these instruments are not obtainable from other sources.

5. Impact on Small Businesses or Other Small Entities

The proposed information collection request does not impact small businesses or other small entities. This information collection primarily affects 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

Follow-up evaluations and specialist referrals for mental health services occur as recommended by the healthcare provider. The forms are completed by the conclusion of the evaluation and returned to care provider program staff who then enter the data into ORR’s electronic record system within 48 hours, or sooner if the evaluation was urgent/emergent.

Care provider staff complete the corresponding Public Health Investigation Form within 48 hours of a reported potential exposure to a reportable infectious disease. Performing the data collection less frequently would prohibit ORR from tracking, monitoring, and advising on mental and public 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

In accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13) and Office of Management and Budget (OMB) regulations at 5 CFR Part 1320 (60 FR 44978, August 29, 1995), ACF published a notice in the Federal Register announcing the agency’s intention to request an OMB review of this information collection activity. This notice was published on June 1, 2023, Volume 88, Number 105, pages 35879-35880, and provided a sixty-day period for public comment. We did not receive comments.

9. Explanation of Any Payment or Gift to Respondents

No monetary incentives or gifts are provided to respondents.

10. Assurance of Confidentiality Provided to Respondents

ORR established a system of records to ensure the level of confidentiality pursuant to the Privacy Act. 5 U.S.C. 552a. ORR’s system of records notice was titled “09-80-0321 ORR Division of Children's Services Records” and published on July 18, 2016, at 81 FR 46682.

Deidentified data is shared with stakeholders (e.g., Department of Health and Human Services leadership, Congress, The Centers for Disease Control and Prevention) on an ad hoc basis several times a year. Examples of shared data include the number of children admitted to residential treatment centers and the number of exposures to reportable infectious diseases. Confidential information is only shared with relevant stakeholders for public health purposes (e.g., contact investigations of reportable infectious diseases).

11. Justification for Sensitive Questions

ORR collects sensitive health information on medical and social history, signs/symptoms, mental health status, lab results and diagnoses to monitor, counsel, and treat children as directed by the Flores Agreement. Health evaluations are performed in an opt-out manner where questions are asked, but children have the right to refuse to respond. Recorded information becomes part of the child’s health record and is viewable only to care provider program staff who are directly responsible for the child, ORR field-based program managers, and ORR federal staff. Children are provided with copies of their health records at the time of discharge from ORR custody with the expectation that collected information will be shared with their new healthcare providers.

12. Estimates of Annualized Burden Hours and Costs

The calculation of annual burden estimates is 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. during fiscal years 2021 and 2022, ORR estimates that the number of children will be approximately 125,800 annually.

• ORR currently funds approximately 250 care provider programs and 1 influx care facility and expects to continue the trend of increasing capacity each year.

• Estimates on the total number of responses per respondent annually were derived from UC Portal data from May 2022 through May 2023.

• Recordkeeping burden, including entering data from the forms into ORR’s secure electronic record system and uploading documentation of all health-related services rendered, will be incurred only by care provider program staff; healthcare providers will not incur recordkeeping burden for this collection.

• The cost to respondents was calculated using hourly wage data, accessed in May 2023, from the Bureau of Labor Statistics (BLS):

• The cost to mental health professional respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Psychiatrists, All Other [29-1223] and wage data from May 2022, which is $118.92 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $237.84. The estimate of annualized cost to respondents for hour burden is $237.84 times 612 hours or $145,558.08.

https://www.bls.gov/oes/current/oes291223.htm

• The cost to care provider program staff respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Child, Family, and School Social Workers in the industry of Other Residential Care Facilities [21-1021] and wage data from May 2022, which is $27.25 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $54.50. The estimate of annualized cost to respondents for hour burden is $54.50 times 8,400 hours or $457,800.00 and for recordkeeping burden, $54.50 times 9,114 hours or $496,713.00.

https://www.bls.gov/oes/current/oes211021.htm

Estimated Reporting Time

Information Collection Title	Respondent	Annual Number of Respondents	Number of Responses Per Respondent	Average Burden Hours Per Response	Annual Burden Hours	Average Hourly Wage	Total Annual Cost
Mental Health Assessment Form	Mental Health Professionals	500	6.8	0.18	612	$237.84	$145,558
Public Health Investigation Form: Active TB	Care Provider Program Staff	500	1	0.08	40	$54.50	$2,180
Public Health Investigation Form: Non-TB Illness		500	200	0.08	8,000		$436,000
Estimated Annual Burden Total:					8,652	Estimated Annual Cost Total:	$583,738

Estimated Recordkeeping Time

Information Collection Title	Respondent	Annual Number of Respondents	Number of Responses Per Respondent	Average Burden Hours Per Response	Annual Burden Hours	Average Hourly Wage	Total Annual Cost
Mental Health Assessment Form	Care Provider Program Staff	500	6.8	0.21	714	$54.50	$38,913
Public Health Investigation Form: Active TB		500	1	0.08	40		$2,180
Public Health Investigation Form: Non-TB Illness		500	200	0.08	8,000		$436,000
Estimated Annual Burden Total:					8,754	Estimated Annual Cost Total:	$477,093

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

There are no other costs to respondents and record keepers.

14. Annualized Cost to the Federal Government

• Form Development and Implementation: The forms were developed by a GS-13, step 6-level public health analyst in the Boston area who spent approximately 100 hours revising the forms. Once ORR procures a new electronic medical record system in 2024, electronic versions of the form will be developed. It is estimated that development of the electronic versions will require 300 hours. To account for fringe benefits and overhead, the hourly rate for this position ($61.94) was multiplied by two for a total of $123.88. Therefore, the cost to create the paper and electronic versions of the form was/will be $49,552.

• Training and quality assurance:

• Training/Guidance documents: Documentation guidance is written by a GS-13, step 6-level public health analyst in the Boston area who spends approximately 120 hours annually performing this task. To account for fringe benefits and overhead, the hourly rate for this position ($61.94) was multiplied by two for a total of $123.88. Therefore, the annual cost to write documentation guidance will be $14,866.

• Trainings and quality assurance: ORR employs 8 contractors to train care providers on documentation and to perform quality assurance checks on entered data. Collectively, the contractors spend approximately 7,488 hours annually completing these tasks. The hourly rate for this position including fringe benefits and overhead is $84.07. Therefore, the annual cost to train staff on proper documentation and perform data quality assurance activities is $629,516.

• Data analysis: Data collected from the forms and entered into ORR’s electronic data record system is analyzed by a GS-12, step 5-level IT Manager in the Washington DC area who spends approximately 936 hours annually performing this task. To account for fringe benefits and overhead, the hourly rate for this position ($51.15) was multiplied by two for a total of $102.30. Therefore, the annual cost to analyze the data collected on the Mental Health Assessment Form and Public Health Investigation Forms is $95,753.

It is estimated that the annual cost to the government for this information collection is $789,687 over the next 3 years.

15. Explanation for Program Changes or Adjustments

The former Health Assessment Form used for medical and mental health evaluations has been updated to only capture mental health information collected during evaluations with a psychiatrist, psychiatric nurse practitioner or physician’s assistant, licensed psychologist, any other community based licensed mental health provider (e.g., social worker) and onsite clinicians at residential treatment centers in the ORR network, and renamed to the Mental Health Assessment Form. This change will simplify and streamline the data collection process for healthcare providers as the fields are tailored towards mental health evaluations. In addition, several changes/updates were made 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, 3) reformatting and building out several fields to clarify intent of current high-level specify fields, and 4) adding/revising the physical and mental status exams and diagnoses. These changes were made to ensure the healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner.

On both Public Health Investigation forms, updates were made to the wording of several fields to clarify intent and unnecessary fields were removed to reduce burden.

Lastly, an instructional letter was written for mental health professionals completing the Mental Health Assessment Form that explains the purpose and data collection guidelines (Attachment B). 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.

16. Plans for Tabulation and Publication and Project Time Schedule

ORR does not plan to publish the results of these information collections. Portions of the data from the information collections may be included in public reports, but the primary purpose of the information collections is to allow ORR to identify and track illnesses and conditions that require monitoring, control, and follow-up, and to ensure that care provider programs and healthcare providers are complying with ORR requirements. 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 on the instruments.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

No exceptions are necessary for this information collection.

1 Note that concurrent with this request (2023), we are revising OMB #0970-0466 and as part of that update the title is changing from Initial Medical Exam Form and Dental Exam Form to Medical Assessment Form and Dental Assessment Form