OMB Control No: |
0970-0474 |
Expiration Date: |
|
Estimated Burden: |
10 minutes |
PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to determine eligibility for temporary assistance under the U.S. Repatriation Program during an emergency repatriation. Public reporting burden for this collection of information is estimated to average 0.2 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This collection of information is required to obtain a benefit (42 U.S.C. Section 1313). An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is 0970-0474 and the expiration date is xx/xx/xxxx. If you have any comments on this collection of information, please contact the U.S. Repatriation Program, 330 C St. SW, Washington, D.C. 20201.
The U.S. Repatriation Program was established in 1935 under Section 1113 of the Social Security Act (42 U.S.C. § 1313) to provide temporary assistance to U.S. citizens and their dependents who have been identified by the U.S. Department of State as having returned, or been brought from a foreign country, to the United States because of destitution, illness, war, threat of war, or a similar crisis, and because they are without resources immediately accessible to meet their needs.
The Office of Human Services Emergency Preparedness and Response (OHSEPR), within the U.S. Department of Health and Human Services’ Administration for Children and Families’, manages the U.S. Repatriation Program. OHSEPR leads all federal non-emergency and emergency repatriation training, technical assistance, planning, and operations conducted as part of the U.S. Repatriation Program.
States, territories, counties, and local service providers may use this form to request training and technical assistance on the U.S. Repatriation Program via a web portal account.
Name: Title/Position:
Department: Agency/Office:
Mailing Address: City: State: Zip Code:
Email: Phone:
Employee Type (Select):
State
Territory
County
Nongovernmental or Local Service Provider
Role (Select):
State Emergency Repatriation Coordinator
State Non-Emergency Repatriation Coordinator
Case Manager
State Lead for Planning, Training, Exercises
Finance
Other (Describe):
Requestor Contact Information
Name: Title/Position:
Department: Agency/Office: State/Territory:
Email: Phone:
Training Assistance Request Categories (Select)
Emergency Repatriation – Case Management
Emergency Repatriation – Emergency Repatriation Centers
Emergency Repatriation – Exercises
Emergency Repatriation – State Emergency Repatriation Plan Development and Review
Emergency Repatriation – Financial Reimbursement
Emergency Repatriation – Unaccompanied Minors
Routine Repatriation – Case Management
Routine Repatriation – Escort Services
Routine Repatriation – Financial Reimbursement
Routine Repatriation – Forms
Routine Repatriation – Unaccompanied Minors
U.S. Repatriation Program Eligibility
State Emergency Repatriation Plan Development
Other (Describe):
Desired Training Date(s)
1st Preference: 2nd Preference: 3rd Preference:
Number of Participants: Accessibility Accommodations:
Requestor Contact Information
Name: Title/Position:
Department: Agency/Office: State/Territory:
Email: Phone:
Technical Assistance Request Categories (Select)
Emergency Repatriation – Case Management
Emergency Repatriation – Emergency Repatriation Centers
Emergency Repatriation – Exercises
Emergency Repatriation – State Emergency Repatriation Plan Development and Review
Emergency Repatriation – Financial Reimbursement
Emergency Repatriation – Unaccompanied Minors
Routine Repatriation – Case Management
Routine Repatriation – Escort Services
Routine Repatriation – Financial Reimbursement
Routine Repatriation – Forms
Routine Repatriation – Unaccompanied Minors
U.S. Repatriation Program Eligibility
State Emergency Repatriation Plan Development or Review
Other (Describe):
Describe Technical Assistance Request:
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Mason, Byron (ACF) |
| File Modified | 0000-00-00 |
| File Created | 2023-12-12 |