Serious Medical Procedure (SMR) Request Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Serious Medical Procedure (SMR) Form - For Grantee Staff	Form	New	Repair queued
Form 1 Serious Medical Procedure (SMR) Form - For Healthcare Providers	Form	New	Available
Attachment A - Flores Agreement.docx	Supplementary Document	Uploaded 2020-11-23	Repair queued
Supporting Statement_SMR_Final.docx	Supporting Statement A	Uploaded 2020-11-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
244594	Serious Medical Procedure (SMR) Form - For Grantee Staff	Form	New
244593	Serious Medical Procedure (SMR) Form - For Healthcare Providers	Form	New

ICR Details

OMB Control No:	ICR Reference No: 202011-0970-010
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Serious Medical Procedure (SMR) Request Form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/30/2020

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	390	0
Time Burden (Hours)	74	0
Cost Burden (Dollars)	0	0

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Abstract: The Homeland Security Act (HSA), 6 U.S.C. 279, transferred responsibilities for the care and placement of unaccompanied alien children (UAC) from the Commissioner of the former Immigration and Naturalization Service (INS) to the Director of the Office of Refugee Resettlement (ORR). 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. Children with complex medical/dental conditions may require surgical intervention or procedures in order to maintain and promote their health while in ORR custody. Procedures requiring general anesthesia, surgeries, and invasive diagnostic procedures (e.g., cardiac catheterization, invasive biopsy, amniocentesis) require advance ORR approval. Before a decision can be rendered by ORR, data on clinical indications, risks and benefits of the surgery/procedure, potential adverse outcomes if services not rendered, timeframe for recovery, follow-up care, and points of contact must be collected and submitted to ORR. The form is not required for emergency procedures, procedures performed during hospitalization, or procedures resulting from complication of a previously approved procedure.

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Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Homeland Security Act
  

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 55012	09/03/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 75327	11/25/2020
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
Serious Medical Procedure (SMR) Form - For Healthcare Providers	1	Serious Medical Procedure (SMR) Request Form
Serious Medical Procedure (SMR) Form - For Grantee Staff	1	Serious Medical Procedure (SMR) Request Form

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ICR Summary of Burden

table that charts list 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	390	0	0	390	0	0
Annual Time Burden (Hours)	74	0	0	74	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 information collection.

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Annual Cost to Federal Government: $42,175

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? No

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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: 11/30/2020

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