Serious Medical Procedure (SMR) Request Form

ICR 202311-0970-006

OMB: 0970-0561

Federal Form Document

ICR Details
0970-0561 202311-0970-006
Received in OIRA 202011-0970-010
Serious Medical Procedure (SMR) Request Form
Revision of a currently approved collection   No
Regular 11/17/2023
  Requested Previously Approved
36 Months From Approved 02/29/2024
230 390
37 74
0 0

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 appropriate medical, mental health and dental services. Children identified as having complex medical/dental conditions may require a procedure while in ORR custody to maintain and promote their health and wellbeing. Procedures requiring general anesthesia, surgeries, and invasive diagnostic procedures (e.g., cardiac catheterization, invasive biopsy, amniocentesis) require advance ORR approval. Before ORR can approve, the following data must be collected and submitted to ORR by the care provider program and the lead surgeon - diagnoses, procedure name(s), current procedural terminology (CPT) code(s), clinical indications, potential risks/complications of procedure, timing for procedure/proposed date, potential adverse outcomes if the procedure is not performed, timeframe for recovery, potential follow-up procedures, follow-up care, and points of contact. In certain circumstances, ORR will waive the completion of the SMR form if it is deemed to be in the best interest of the child’s safety and well-being (e.g., during a hospitalization or emergency department visit, medical emergencies).

US Code: 6 USC 279 Name of Law: Homeland Security Act

Not associated with rulemaking

  88 FR 62798 09/13/2023
88 FR 78755 11/16/2023

  Total Request Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 230 390 0 -160 0 0
Annual Time Burden (Hours) 37 74 0 -37 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Miscellaneous Actions
Several changes were made to the SMR Form including, 1) rewriting the intro section and adding guidance on completing and submitting the form, 2) adding fields on consent, procedure name and planned follow-up procedures, 3) rewording existing fields, and 4) removing unnecessary fields. ORR has incorporated these changes to the form to streamline the flow of data collection, clarify intent and purpose of the form and fields, improve data quality, and ensure alignment with ORR program policies. The overall estimated time per form has increased by 1 minute and has been adjusted to reflect a decrease by 1 minute for care provider program staff and an increase by 2 minutes for surgeons.

Molly Buck 202 205-4724 [email protected]


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.

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