NonSub Change - Medical Assessment Form

To: Kelsi Feltz

Office of Information and Regulatory Affairs (OIRA)

Office of Management and Budget (OMB)

From: Kirsten Buckley

Unaccompanied Children Program, Office of Refugee Resettlement

Administration for Children and Families (ACF)

Date: December 05, 2023

Subject: NonSubstantive Change Request – Medical Assessment Form and Dental Assessment Form (OMB #0970-0466)

This memo requests approval of nonsubstantive changes to the approved information collection, Medical Assessment Form and Dental Assessment Form (OMB #0970-0466).

Background

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.

Overview of Requested Changes

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

Time Sensitivities

The goal is for ORR to distribute the updated form to care provider programs by the end of the month when ORR’s updated policy will be released.