Medical Complaint Form, Contact Investigation Form: Non-TB Illness, and Contact Investigation Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Contact Investigation Form: Active/Suspect TB	Form and Instruction	New	Available
Form 1 Contact Investigation Form: Non-TB Illness	Form and Instruction	New	Available
Form 1 Medical Complaint Form	Form and Instruction	New	Available
ORR-0405_SUPSTAT_HHS.docx	Supporting Statement A	Uploaded 2018-02-06	Available
Attachment A - Flores Agreement.doc	Supplementary Document	Uploaded 2018-01-30	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229906	Contact Investigation Form: Active/Suspect TB	Form and Instruction	New
229904	Contact Investigation Form: Non-TB Illness	Form and Instruction	New
229902	Medical Complaint Form	Form and Instruction	New

ICR Details

OMB Control No: 0970-0509	ICR Reference No: 201801-0970-014
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Medical Complaint Form, Contact Investigation Form: Non-TB Illness, and Contact Investigation Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/15/2018
	Date Received in OIRA: 02/06/2018
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2021	36 Months From Approved
Responses	101,040	0	0
Time Burden (Hours)	21,182	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Pursuant to Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK (C.D. Cal. 1996), the Administration for Children and Families’ Office of Refugee Resettlement (ORR), on behalf of the Department of Health and Human Services (DHHS), is directed to provide unaccompanied children in their custody with medical, mental, and dental care until reunification with a qualified sponsor. Licensed care provider facilities, on behalf of ORR, are required to ensure that all children receive a complete medical examination within 48 business hours of admission including screening for infectious diseases and immunizations recommended by the U.S. Public Health Service (PHS), the Center for Disease Control and Prevention. Additional required services include routine medical and dental care, family planning services, and emergency healthcare. ORR requires care provider facilities to maintain records on each child to ensure that health-related evaluations, diagnosed illnesses/conditions, immunizations, and treatments are documented, monitored, and included in the child’s discharge packet at the time of reunification. ORR requires the Medical Complaint and Contact Investigation (Active/Suspect TB and Non-TB Illness) information collections to implement and maintain compliance with the Flores Settlement Agreement.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 28489	06/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 3731	01/26/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Medical Complaint Form	1	Medical Complaint Form
Contact Investigation Form: Active/Suspect TB	1	Contact Investigation Form Active and Suspect
Contact Investigation Form: Non-TB Illness	1	Contact Investigation Form

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	101,040	0	0	101,040	0	0
Annual Time Burden (Hours)	21,182	0	0	21,182	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $131,653

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.     No

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? Uncollected

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Common Form ICR:  No

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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: 02/06/2018

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