Medical Assessment Form - Reporting Time for Pediatricians, General

Medical Assessment Form and Dental Assessment Form

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Medical Assessment Form - Reporting Time for Pediatricians, General Form
1 Medical Assessment Form ORR Medical Assessment Form.docx Form
1 Medical Assessment Form ORR Medical Assessment Form.docx Form
Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx Attachment B - Medical Assessment Form Instructional Letter for Medical Providers IC Document
Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx Attachment B - Medical Assessment Form Instructional Letter for Medical Providers IC Document

Information Collection (IC) Details

IC Title:	Medical Assessment Form - Reporting Time for Pediatricians, General	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Medical Assessment Form	ORR Medical Assessment Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: ORR Division of Children's Services Records	FR Citation: 81 FR 46682

Number of Respondents: 300	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	252,000	199,155	52,845
Annual IC Time Burden (Hours)	55,440	23,733	31,707
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Attachment B - Medical Assessment Form Instructional Letter for Medical Providers	Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx	08/02/2023

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.