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Dental Assessment Form - Recordkeeping Time
Medical Assessment Form and Dental Assessment Form
OMB: 0970-0466
IC ID: 261420
OMB.report
HHS/ACF
OMB 0970-0466
ICR 202308-0970-002
IC 261420
( )
⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0466 can be found here:
2023-12-06 - No material or nonsubstantive change to a currently approved collection
Documents and Forms
Document Name
Document Type
Form 1
Dental Assessment Form - Recordkeeping Time
Form
1 Dental Assessment Form
ORR Dental Assessment Form.docx
Form
1 Dental Assessment Form
ORR Dental Assessment Form.docx
Form
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx
Attachment C - Dental Assessment Form Instructional Letter for Dental Providers
IC Document
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx
Attachment C - Dental Assessment Form Instructional Letter for Dental Providers
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Dental Assessment Form - Recordkeeping Time
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
Dental Assessment Form
ORR Dental Assessment Form.docx
Yes
Yes
Fillable Fileable
Federal Enterprise Architecture Business Reference Module
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 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
16,000
0
16,000
0
0
0
Annual IC Time Burden (Hours)
2,720
0
2,720
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Attachment C - Dental Assessment Form Instructional Letter for Dental Providers
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx
08/02/2023
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.