Medical Assessment Form - Reporting Time for Medical Specialist, 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⚠️ Notice: This information collection may be referencing outdated material.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 Medical Specialist, 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 Medical Specialist, General	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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: 750	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
Annual Number of Responses for this IC	16,500	16,500
Annual IC Time Burden (Hours)	3,630	3,630
Annual IC Cost Burden (Dollars)	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.