Medical Assessment Form and Dental Assessment Form
Revision of a currently approved collection
No
Regular
Approved without change
10/26/2023
08/08/2023
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
10/31/2026
36 Months From Approved
12/31/2023
619,000
0
61,815
160,815
0
33,950
0
0
0
The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the Medical Assessment Form (formerly, the Initial Medical Exam Form and Supplemental Tuberculosis Screening Form) and Dental Assessment Form (formerly, the Dental Exam Form) (OMB #0970-0466, expiration 12/31/2023).
The ACF Office of Refugee Resettlement (ORR) places unaccompanied children in their custody in care provider programs until unification with a qualified sponsor. Care provider programs are required to ensure children receive appropriate medical, mental health and dental services.
Per ORR requirements, each child must receive an initial medical exam (IME) within 2 business days of admission to an ORR care provider program or temporary influx care facility (ICF). The IME satisfies Flores requirements which require a âcomplete medical examination, including a screening for infectious disease. See Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A). The purposes of the IME are to assess general health, administer vaccinations in keeping with U.S. standards (also required by Flores), identify health conditions that require further attention, and detect contagious diseases of public health importance, such as influenza or tuberculosis. The IME is performed by a licensed health care provider and comprised of a complete medical history and physical exam, risk- and age-based laboratory screenings, tuberculosis screenings and immunizations. Children who are in ORR custody 60 to 90 days after admission must receive an initial dental exam, or sooner if directed by state licensing requirements. Children who are in ORR care for an extended length of time may also require routine medical and dental well-child evaluations. In addition, children may be referred to a medical or dental specialist by their healthcare provider for acute or chronic conditions that require additional evaluation, or they may need emergent/urgent care services.
ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, immunizations, and treatments are documented and included in the childâs discharge packet at the time of unification with their sponsor. ORR requires the Medical Assessment and Dental Assessment information collections to implement and maintain compliance with the Flores Settlement Agreement.
The currently approved information collection includes an Initial Medical Exam Form and a Supplemental TB Screening Form. Data collection for all other medical evaluations is conducted on the Health Assessment Form under forms approved under OMB #0970-0509 . This new request merges the medical data from the three forms into a single Medical Assessment Form that will be used during all evaluations with a mid-level, or higher medical professional (e.g., medical doctor, nurse practitioner), including the IME. This change will simplify and streamline the data collection process for healthcare providers as the same form will be used for every medical assessment regardless of the reason for the visit.
In addition, several changes were made to the Medical and Dental Assessment Forms including, 1) adding fields to the General Information section to capture information on translation services and purpose of visit, 2) enhancing the History and Physical Assessment section to obtain a more thorough health and social history, and 3) reformatting and building out several fields to clarify intent of current high-level specify fields. Other updates made solely to the Medical Assessment Form include the addition/revision of the physical and mental status exams, diagnoses, and lab testing requirements. These changes were made to ensure healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner. Adjustments were made to the lab testing requirements in accordance with the changes made to ORRâs IME requirements.
Lastly, instructional letters have been written for each respondent completing an Assessment Form that explain the purpose and data collection guidelines for each form (Attachments B and C). Adjustments have been made to burden estimates where applicable and burden estimates have been broken out to display burden more clearly for each type of respondent and activity.
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.
Dental Assessment Form - Recordkeeping Time