Serious Medical Procedure (SMR) Request Form

Forms and Documents

Document Name	Status
Form 1 Serious Medical Procedure (SMR) Form - Care provider program staff Form	Modified
Form 1 Serious Medical Procedure (SMR) Form - Pediatric surgeons Form	Modified
Attachment A_Flores Agreement.docx Supplementary Document	2023-11-15
Supporting Statement A_SMR Form_cln_KB.docx Supporting Statement A	2023-11-15

IC Document Collections

IC ID	Document Title	Status
244594	Serious Medical Procedure (SMR) Form - Care provider program staff Form	Modified
244593	Serious Medical Procedure (SMR) Form - Pediatric surgeons Form	Modified

ICR Details

OMB Control No: 0970-0561	ICR Reference No: 202311-0970-006
Status: Received in OIRA	Previous ICR Reference No: 202011-0970-010
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Serious Medical Procedure (SMR) Request Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/17/2023

	Requested	Previously Approved
Expiration Date	36 Months From Approved	02/29/2024
Responses	230	390
Time Burden (Hours)	37	74
Cost Burden (Dollars)	0	0

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Abstract: 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).

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Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Homeland Security Act
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 62798	09/13/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 78755	11/16/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title	Form No.	Form Name
Serious Medical Procedure (SMR) Form - Care provider program staff	1	Serious Medical Procedure (SMR) Request Form
Serious Medical Procedure (SMR) Form - Pediatric surgeons	1	Serious Medical Procedure (SMR) Request Form

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ICR Summary of Burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: 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.

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Annual Cost to Federal Government: $92,749

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 11/17/2023

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