Initial Medical Exam Form and Dental Exam Form

ICR 202205-0970-003

OMB: 0970-0466

Federal Form Document

Forms and Documents
Justification for No Material/Nonsubstantive Change
Supporting Statement A
Supplementary Document
IC Document Collections
217789 Unchanged
217788 Modified
ICR Details
0970-0466 202205-0970-003
Received in OIRA 202009-0970-012
Initial Medical Exam Form and Dental Exam Form
No material or nonsubstantive change to a currently approved collection   No
Regular 05/09/2022
  Requested Previously Approved
12/31/2023 12/31/2023
61,815 61,815
33,950 33,950
0 0

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). The Initial Medical Exam is performed by a mid-level medical professional or higher and includes a psychosocial risk evaluation that is used to identify potential mental health concerns or symptoms. To capture these concerns and symptoms, disorder-based mental health diagnosis options were listed in the Behavioral and Mental Health Concerns category within the Diagnosis section of the current Initial Medical Exam Form. However, since the date of approval, an ORR Behavioral and Mental Health Team comprised of licensed mental health professionals was created and after careful consideration, the Team believes the current format may cause a child to be prematurely and inappropriately labeled with a mental health disorder. Per ORR guidelines, a child identified with a symptom-based diagnosis at the Initial Medical Exam would be referred to a specialist for evaluation and a disorder-based diagnosis which would be captured in the Health Assessment form (OMB #0970-0509). Therefore, ORR feels that it is in the best interest of the child to provide symptom-based mental health diagnoses in lieu of disorder-based diagnoses on the Initial Medical Exam Form.

US Code: 6 USC 279 Name of Law: Flores Agreement

Not associated with rulemaking

  85 FR 15477 03/18/2020
85 FR 60801 09/28/2020

IC Title Form No. Form Name
Dental Exam Form 1 Dental Exam Form
Initial Medical Exam Form 1, 1 Initial Medical Exam Form ,   Appendix A_Supplemental TB Screening Form

  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 61,815 61,815 0 0 0 0
Annual Time Burden (Hours) 33,950 33,950 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0

Molly Buck 202 205-4724 [email protected]


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:
    (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;
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.

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