ORR-6 Schedule F

Schedule F: Refugee Medical Assistance (RMA) and Medical Screening			ORR-6 OMB Control No. 0970-0036 Expires xx-xx-xxxx
1. Annual Report, Fiscal Year:		2. Date:
3. State/Grantee:
Part I: Refugee Medical Assistance Recipients and Benefits
A. RMA Enrollment Caseload	Total	C. RMA Recipient Use by Cost Range	Total
1. Previous RMA recipients enrolled in this reporting period		1. No costs incurred
2. New RMA recipients enrolled during this reporting period		2. $1 - $10,000
3. Total number of RMA recipients enrolled during this reporting period	0	3. $10,001 - $150,000
B. RMA Termination Reason	Total	4. $150,001 - $350,000
1. Reached 8 month time-eligibility		5. Over $350,000
2. Transitioned to Medicaid
3. Out-Migrated
4. Other
5. Total number of RMA terminations	0
Part II: Medical Screening Recipients
A. Timeliness of Medical Screenings	Total	C. Funding Source of Medical Screening Completions	Total
1. Recipients who completed a screening within 30 days from arrival		1. Recipients who completed a screening funded ONLY by CMA
2. Recipients who completed a screening within 31-90 days from arrival		2. Recipients who completed a screening partially funded by CMA
3. Recipients who completed a screening beyond 90 days from arrival		3. Total recipients who completed a screening in this reporting period
4. Total recipients who completed a screening in this reporting period	0	D. Screening recipient completions by eligibility status	Total
B. Class A, B1, and B2 Cases Screening Completions	Total	1. Refugee
1. Class A, B1, and B2 cases arrived		2. Asylee
2. Class A, B1, and B2 cases who completed a screening		3. SIV
3. Class A, B1, and B2 medical screening completion rate	#DIV/0!	4. Cuban/Haitian Entrant
		5. Other
		E. Screening recipient completions by age	Total
		1. Child < 18 years
		2. Adult ≥ 18 years
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Schedule F: RMA and Medical Screening continue
Part III: Medical Screening Services
A. Lead Screening	Total	F. Tuberculosis Screening	Total
1. Children tested for lead (first test)		1. Recipients who completed a TST
B. Mental Health Screening	Total	2. Recipients tested with IGRA
1. Recipients provided a mental health screening		G. Hepatitis B Screening	Total
a. Recipients referred for further evaluation and counseling		1. Recipients tested for hepatitis B (surface antigen)
C. Parasite Screening	Total	H. Hepatitis C Screening	Total
1. Recipients who completed tests for parasitic infectionss		1. Recipients tested for hepatitis C (HCV antibody test)
D. Domestic Presumptive Treatment	Total	I. Syphilis Screening	Total
1. Recipients presumptively treated		1. Recipients tested for syphilis (VDRL/RPR)
a. Recipients presumptively treated for strongyloidiasis		J. Chlamydia Screening	Total
b. Recipients presumptively treated for schistosomiasis		1. Recipients tested for chlamydia
c. Recipients presumptively treated for soil-transmitted helminths		K. Gonorrhea Screening	Total
d. Recipients presumptively treated for malaria		1. Recipients tested for gonorrhea
E. HIV Screening	Total	L. Primary Care Referrals	Total
1. Recipients tested for HIV		1. Recipients referred to primary care
Part IV: Data Explanations and Trends
A. Explain Anomalies in Parts I, II, and III (e.g., missing data due to reporting issues)
B. Report emerging health trends (e.g., new cases of certain health conditions)
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