Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB
Revision of a currently approved collection
No
Regular
Approved without change
09/16/2023
08/08/2023
table that charts list comparision
Inventory as of this Action
Requested
Previously Approved
09/30/2026
36 Months From Approved
12/31/2023
207,800
0
108,225
17,406
0
38,454
0
0
0
The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the forms Mental Health Assessment Form (formerly, the Health Assessment Form), Public Health Investigation Form: Active TB and Public Health Investigation Form: Non-TB Illness (OMB #0970-0509, expiration 12/31/2023). Revisions are proposed to the currently approved forms as described in section A15.
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 the appropriate medical, mental health and dental services per the Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A).
While in care, children meet with onsite mental health counselors on a regular basis. If a child is identified as potentially having a more serious mental health condition, they are referred to a psychiatrist, psychiatric nurse practitioner or physicianâs assistant, licensed psychologist, or other licensed mental health provider (e.g., social worker).
Children may be exposed to nationally reportable infectious diseases during the journey to the U.S., while in the custody of the Customs and Border Protection after crossing the border, or during their stay in ORR custody. Public health interventions such as quarantine, vaccination or lab testing may be initiated to reduce possible disease transmission. Following an exposure, children are assessed onsite by care provider program staff and if found to be symptomatic, referred to a healthcare provider for evaluation.
ORR requires care providers to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, and treatments are documented and included in the childâs discharge packet at the time of reunification. ORR requires the Mental Health Assessment and Public Health Investigation Forms information collections to implement and maintain compliance with the Flores Settlement Agreement.
US Code:
6 USC 279
Name of Law: Flores Settlement Agreement
The former Health Assessment Form used for medical and mental health evaluations has been updated to only capture mental health information collected during evaluations with a psychiatrist, psychiatric nurse practitioner or physicianâs assistant, licensed psychologist, any other community based licensed mental health provider (e.g., social worker) and onsite clinicians at residential treatment centers in the ORR network, and renamed to the Mental Health Assessment Form. This change will simplify and streamline the data collection process for healthcare providers as the fields are tailored towards mental health evaluations. In addition, several changes/updates were made 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, 3) reformatting and building out several fields to clarify intent of current high-level specify fields, and 4) adding/revising the physical and mental status exams and diagnoses. These changes were made to ensure the healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner.
On both Public Health Investigation forms, updates were made to the wording of several fields to clarify intent and unnecessary fields were removed to reduce burden.
Lastly, an instructional letter was written for mental health professionals completing the Mental Health Assessment Form that explains the purpose and data collection guidelines (Attachment B). 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.
Public Health Investigation Form: Non-TB Illness - Recordkeeping Time