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

Forms and Documents

Document Name	Status
Form 1 Public Health Investigation Form: Non-TB Illness - Recordkeeping Time Form	Modified
Form 1 Public Health Investigation Form: Active TB - Recordkeeping Time Form	Modified
Form 1 Mental Health Assessment Form - Recordkeeping Time Form	Modified
Form 1 Public Health Investigation Form: Non-TB Illness - Reporting Time Form	Modified
Form 1 Public Health Investigation Form: Active TB - Reporting Time Form	Modified
Form 1 Mental Health Assessment Form - Reporting Time Form	Modified
NonSub Change - Update to ACF ICs - Protecting Women EO - Submission 2.10.25.docx Justification for No Material/Nonsubstantive Change	2025-02-10
NonSub Change Request_0466 and 0509_FINAL_10.4.24 (002).docx Justification for No Material/Nonsubstantive Change	2024-10-04
30 Day FRN_Data Sharing Updates _0970-0466 and 0970-0509_7.2.24.pdf Supplementary Document	2024-10-04
NonSub Change Request - MH Assessment Form and PH Ivest Forms -ROCIS title.docx Justification for No Material/Nonsubstantive Change	2023-09-18
Supporting Statement A_Mental Health Assessment and Public Health Investigation Forms_v2.docx Supporting Statement A	2024-10-04
Attachment B_Mental Health Assessment Form Instructional Letter for Mental Health Providers.docx Supplementary Document	2023-08-03
Attachment A_Flores Agreement.docx Supplementary Document	2023-08-03

IC Document Collections

IC ID	Document Title	Status
261448	Public Health Investigation Form: Non-TB Illness - Recordkeeping Time Form	Modified
261447	Public Health Investigation Form: Active TB - Recordkeeping Time Form	Modified
261446	Mental Health Assessment Form - Recordkeeping Time Form	Modified
229906	Public Health Investigation Form: Non-TB Illness - Reporting Time Form	Modified
229904	Public Health Investigation Form: Active TB - Reporting Time Form	Modified
229902	Mental Health Assessment Form - Reporting Time Form	Modified

ICR Details

OMB Control No: 0970-0509	ICR Reference No: 202502-0970-014
Status: Received in OIRA	Previous ICR Reference No: 202410-0970-005
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/15/2025

	Requested	Previously Approved
Expiration Date	09/30/2026	09/30/2026
Responses	207,800	207,800
Time Burden (Hours)	17,406	17,406
Cost Burden (Dollars)	0	0

---

Abstract: The Mental Health Assessment Form was approved by OMB on September 16, 2023, as part of the Mental Health Asessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness Form information collection. The purpose of the Mental Health Assessment is to collect standardized health information on unaccompanied children during evaluations with mental health providers. The following two Administration for Children and Families (ACF) Office of Refugee Resettlement (ORR) information collections capture health data on children in ORR care: • Medical Assessment Form and Dental Assessment Form • Mental Health Assessment Form and Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness. ORR has recently identified a specific need to share data collected on ORR’s health assessment forms that falls outside of the stated limitations with the Department of Homeland Security (DHS). The need to communicate with DHS occurs when a newly referred child arrives at an ORR facility ill or requires emergent/urgent healthcare services shortly after placement and ORR was not notified in advance. For DHS to investigate the event, ORR must share confidential and sensitive health information including the child’s alien number, name, signs/symptoms, diagnoses, and date of diagnosis. The goal of this data sharing effort is to identify areas of potential improvement in delivery of healthcare services and continuity of care for children transferred from DHS to HHS custody. ACF has implemented changes to update gender collected data to denote sex as a biological variable in current approved information collection requests to comply with recent presidential directives.

---

Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores Settlement Agreement
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 35879	06/01/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 52172	08/07/2023
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Mental Health Assessment Form - Recordkeeping Time	1	Mental Health Assessment Form
Mental Health Assessment Form - Reporting Time	1	Mental Health Assessment Form
Public Health Investigation Form: Active TB - Recordkeeping Time	1	Public Health Investigation Form: Active TB
Public Health Investigation Form: Active TB - Reporting Time	1	Public Health Investigation Form: Active TB
Public Health Investigation Form: Non-TB Illness - Recordkeeping Time	1	Public Health Investigation Form: Non-TB Illness
Public Health Investigation Form: Non-TB Illness - Reporting Time	1	Public Health Investigation Form: Non-TB Illness

---

ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	207,800	207,800	0	0	0	0
Annual Time Burden (Hours)	17,406	17,406	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $789,687

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

---

Common Form ICR:  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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 02/15/2025

---