U.S. Repatriation Program Forms

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Repatriation Training and Technical Assistance Request Form	Form	New	Repair queued
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified	Repair queued
Form RR-07 Temporary Assistance Extension Request	Form and Instruction	Modified	Repair queued
Form RR-06 Refusal of Temporary Assistance	Form and Instruction	Modified	Repair queued
Form RR-05 Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified	Repair queued
Form RR-04 Routine Repatriation Reimbursement Request	Form and Instruction	Modified	Repair queued
Form RR-03 Loan Waiver and Deferral Application	Form and Instruction	Modified	Available
Form RR-02 Emergency Repatriation Reimbursement Request	Form and Instruction	Modified	Repair queued
Form RR-01 Emergency Repatriation Eligibility Application	Form and Instruction	Modified	Repair queued
Supporting Statement A - OHSEPR Repat Forms PTE TTA_0970-0474_CLEAN_Nov152023.docx	Supporting Statement A	Uploaded 2023-11-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
263518	Repatriation Post-Training Survey	Other-Survey	New
263517	Repatriation Training and Technical Assistance Request Form	Form	New
263516	Repatriation State Contact List	Other-Contact List	New
263515	Planning, Training, and Exercise – Budget and Budget Narrative	Other-Narrative	New
263514	Planning, Training, and Exercise – Annual Workplan	Other-Workplan	New
263513	Planning, Training, and Exercise – Project Narrative	Other-Narrative	New
218660	Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Modified
218659	Temporary Assistance Extension Request	Form and Instruction	Modified
218658	Refusal of Temporary Assistance	Form and Instruction	Modified
218657	Repatriation Repayment and Privacy Agreement	Form and Instruction	Modified
218656	Routine Repatriation Reimbursement Request	Form and Instruction	Modified
218655	Loan Waiver and Deferral Application	Form and Instruction	Modified
218654	Emergency Repatriation Reimbursement Request	Form and Instruction	Modified
218653	Emergency Repatriation Eligibility Application	Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 202311-0970-008
Status: Received in OIRA	Previous ICR Reference No: 202304-0970-011
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: U.S. Repatriation Program Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/27/2023

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved	06/30/2025
Responses	5,140	2,535
Time Burden (Hours)	1,470	802
Cost Burden (Dollars)	0	0

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Abstract: The U.S. Repatriation Program (Program) is authorized by Section 1113 of the Social Security Act (42 U.S.C. § 1313) and the assistance provided to mentally ill repatriates found under 24 U.S.C. §§ 321 - 329. This Program also provides services for emergency repatriations which are authorized under Section 1113 and by the extension of the Executive Order (E.O.) precedent, E.O. 12656 (53 CFR 47491). Program regulations are in 45 CFR 211 & 212. The current collection includes eight forms with translations in six languages. The information collected through these forms allows the Office of Human Services Emergency Preparedness and Response (OHSEPR) to fulfill its statutory responsibilities to provide temporary assistance to repatriates. The Program also provides training and technical assistance to states and territories for routine and emergency repatriation. Additionally, OHSEPR provides funding to states for emergency repatriation planning, training, and exercises. OHSEPR is proposing six new forms to support these activities.

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Authorizing Statute(s): EO: EO 12656 Name/Subject of EO: Assignment of Emergency Preparedness Responsibilities
   US Code: 24 USC 321-329 Name of Law: Hospitals and Asylums
   US Code: 42 USC 1313 Name of Law: Social 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 15728	03/14/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 81087	11/21/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 14

table that charts list of burden

IC Title	Form No.	Form Name
Emergency Repatriation Eligibility Application	RR-01, RR-01 , RR-01, RR-01, RR-01, RR-01, RR-01	Emergency Repatriation Eligibility Application ,   Emergency Repatriation Eligibility Application - Arabic ,   Emergency Repatriation Eligibility Application - French ,   Emergency Repatriation Eligibility Application - Russian ,   Emergency Repatriation Eligibility Application - Simplified Chinese ,   Emergency Repatriation Eligibility Application - Spanish ,   Emergency Repatriation Eligibility Application - Traditional Chinese
Emergency Repatriation Reimbursement Request	RR-02, RR-02, RR-02, RR-02, RR-02, RR-02, RR-02	Emergency Repatriation Reimbursement Request ,   Emergency Repatriation Reimbursement Request - Arabic ,   Emergency Repatriation Reimbursement Request - French ,   Emergency Repatriation Reimbursement Request - Russian ,   Emergency Repatriation Reimbursement Request - Simplified Chinese ,   Emergency Repatriation Reimbursement Request - Spanish ,   Emergency Repatriation Reimbursement Request - Traditional Chinese
Emergency Repatriation Request for Cost Approval and Federal Support	RR-08, RR-08, RR-08, RR-08, RR-08, RR-08, RR-08	Emergency Repatriation Request for Cost Approval and Federal Support ,   Emergency Repatriation Request for Cost Approval and Federal Support - Arabic ,   Emergency Repatriation Request for Cost Approval and Federal Support - French ,   Emergency Repatriation Request for Cost Approval and Federal Support - Russian ,   Emergency Repatriation Request for Cost Approval and Federal Support - Simplified Chinese ,   Emergency Repatriation Request for Cost Approval and Federal Support - Spanish ,   Emergency Repatriation Request for Cost Approval and Federal Support - Traditional Chinese
Loan Waiver and Deferral Application	RR-03, RR-03, RR-03, RR-03, RR-03, RR-03, RR-03	Loan Waiver and Deferral Application ,   Loan Waiver and Deferral Application - Arabic ,   Loan Waiver and Deferral Application - French ,   Loan Waiver and Deferral Application - Russian ,   Loan Waiver and Deferral Application - Simplified Chinese ,   Loan Waiver and Deferral Application - Spanish ,   Loan Waiver and Deferral Application - Traditional Chinese
Planning, Training, and Exercise – Annual Workplan
Planning, Training, and Exercise – Budget and Budget Narrative
Planning, Training, and Exercise – Project Narrative
Refusal of Temporary Assistance	RR-06, RR-06, RR-06, RR-06, RR-06, RR-06, RR-06	Refusal of Temporary Assistance ,   Refusal of Temporary Assistance - Arabic ,   Refusal of Temporary Assistance - French ,   Refusal of Temporary Assistance - Russian ,   Refusal of Temporary Assistance - Simplified Chinese ,   Refusal of Temporary Assistance - Spanish ,   Refusal of Temporary Assistance - Traditional Chinese
Repatriation Post-Training Survey
Repatriation Repayment and Privacy Agreement	RR-05, RR-05, RR-05, RR-05, RR-05, RR-05, RR-05	Repatriation Repayment and Privacy Agreement ,   Repatriation Repayment and Privacy Agreement - Arabic ,   Repatriation Repayment and Privacy Agreement - French ,   Repatriation Repayment and Privacy Agreement - Russian ,   Repatriation Repayment and Privacy Agreement - Simplified Chinese ,   Repatriation Repayment and Privacy Agreement - Spanish ,   Repatriation Repayment and Privacy Agreement - Traditional Chinese
Repatriation State Contact List
Repatriation Training and Technical Assistance Request Form	1	Repatriation Training and Technical Assistance Request Form
Routine Repatriation Reimbursement Request	RR-04, RR-04, RR-04, RR-04, RR-04, RR-04, RR-04	Routine Repatriation Reimbursement Request ,   Routine Repatriation Reimbursement Request - Arabic ,   Routine Repatriation Reimbursement Request - French ,   Routine Repatriation Reimbursement Request - Russian ,   Routine Repatriation Reimbursement Request - Simplified Chinese ,   Routine Repatriation Reimbursement Request - Spanish ,   Routine Repatriation Reimbursement Request - Traditional Chinese
Temporary Assistance Extension Request	RR-07, RR-07, RR-07, RR-07, RR-07, RR-07, RR-07	Temporary Assistance Extension Request ,   Temporary Assistance Extension Request - Arabic ,   Temporary Assistance Extension Request - French ,   Temporary Assistance Extension Request - Russian ,   Temporary Assistance Extension Request - Simplified Chinese ,   Temporary Assistance Extension Request - Spanish ,   Temporary Assistance Extension Request - Traditional Chinese

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ICR Summary of Burden

table that charts list 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	5,140	2,535	0	2,550	55	0
Annual Time Burden (Hours)	1,470	802	0	613	55	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This request is for additional data collection under OMB #0970-0474 to collect data to support new emergency repatriation grants and the provision of training and technical assistance. We are also requesting to extend approval of the currently approved forms without changes.

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Annual Cost to Federal Government: $212,612

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: 11/27/2023

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