Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB

ICR 202205-0970-004

OMB: 0970-0509

Federal Form Document

Forms and Documents
Justification for No Material/Nonsubstantive Change
Supporting Statement A
Supplementary Document
IC Document Collections
ICR Details
0970-0509 202205-0970-004
Received in OIRA 202009-0970-013
Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB
No material or nonsubstantive change to a currently approved collection   No
Regular 05/09/2022
  Requested Previously Approved
12/31/2023 12/31/2023
108,225 108,225
38,454 38,454
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 health, 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 emergent, routine and as-needed healthcare as directed by ORR, including “sick visits”, follow-up immunizations, urgent healthcare, and family planning services. Initial medical and dental and routine dental care are also required services for minors in ORR custody (OMB #0970-0466). 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 Health Assessment and Public Health Investigation information collections to implement and maintain compliance with the Flores Settlement Agreement. To capture behavioral and mental health concerns and symptoms during these evaluations, disorder-based mental health diagnosis options were listed in the Behavioral and Mental Health Concerns category within the Diagnosis section of the current Health Assessment 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 if the child is first evaluated by a non-mental health provider. Per ORR guidelines, a child identified with a symptom-based diagnosis during an evaluation with a healthcare provider would be referred to a specialist for evaluation and a disorder-based diagnosis. Therefore, ORR feels that it is in the best interest of the child to provide symptom-based mental health diagnoses as well as disorder-based diagnoses on the Health Assessment Form.

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

Not associated with rulemaking

  85 FR 15476 03/18/2020
85 FR 60802 09/28/2020

  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 108,225 108,225 0 0 0 0
Annual Time Burden (Hours) 38,454 38,454 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
In the previously approved information collection, the annual burden estimate did not include the time required by healthcare providers to complete the Health Assessment form, 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 to fill out the ORR-developed Health Assessment form, however, ORR has since increased the burden estimate for this request.

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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