Information Collection

Medical Assessment Form - Recordkeeping Time (information obtained via health records)

IC 261419 under ICR 202308-0970-002 · OMB 0970-0466.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medical Assessment Form - Recordkeeping Time (information obtained via health records)	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

IC Title:

Medical Assessment Form - Recordkeeping Time (information obtained via health records)

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:

table that charts list of 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: 500

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	50,000	50,000
Annual IC Time Burden (Hours)	8,500	8,500
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.