Initial Medical Exam Form and Dental Exam Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Dental Exam Form	Form	Modified	Available
Form 1 Initial Medical Exam Form	Form	Modified	Available
SUPSTAT_HHS OMB 0970-0466_Final.docx	Supporting Statement A	Uploaded 2020-09-28	Repair queued
Attachment A - Flores Agreement.doc	Supplementary Document	Uploaded 2015-08-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
217789	Dental Exam Form	Form	Modified
217788	Initial Medical Exam Form	Form	Modified

ICR Details

OMB Control No: 0970-0466	ICR Reference No: 202009-0970-012
Status: Active	Previous ICR Reference No: 202003-0970-006
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Initial Medical Exam Form and Dental Exam Form
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 12/10/2020
	Date Received in OIRA: 09/28/2020
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2023	36 Months From Approved	12/31/2020
Responses	61,815	0	49,050
Time Burden (Hours)	33,950	0	14,085
Cost Burden (Dollars)	0	0	0

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Abstract: ACF is requesting an extension of the information collection previously approved under emergency clearance in March of 2020. 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. Unaccompanied minors in ORR custody are placed in grantee-operated licensed care provider facilities that arrange for appropriate healthcare as directed by ORR. All children are required to receive a complete medical examination including screening for infectious diseases and immunizations recommended by the Centers for Disease Control and Prevention within 2 business days of admission into an ORR-funded licensed care provider facility. If children are still in ORR custody 60 to 90 days after admission, they are required to receive an initial dental exam, or sooner if directed by state licensing requirements. Additional required services include routine medical and dental care, family planning, and emergency health care. ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnosed conditions/illnesses, immunizations, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Initial Medical Exam and Dental Exam information collections to implement and maintain compliance with the Flores Settlement Agreement (Attachment A).

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

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:
	85 FR 15477	03/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60801	09/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Initial Medical Exam Form	1, 1	Initial Medical Exam Form ,   Appendix A_Supplemental TB Screening Form
Dental Exam Form	1	Dental Exam 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	61,815	49,050	0	12,765	0	0
Annual Time Burden (Hours)	33,950	14,085	0	19,865	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: In the previously approved information collection, the annual burden estimate did not include the time required by healthcare providers and dentists to complete the forms, as it was assumed this information was already collected by the provider and did not impose additional burden. In order to account for the time needed for healthcare providers and dentists to fill out the ORR-developed forms, however, ORR has since increased the burden estimate for this request.

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Annual Cost to Federal Government: $22,187

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

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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: 09/28/2020

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