The Medical Assessment Form was approved by OMB on October 26, 2023, as part of the Medical Assessment Form and Dental Assessment Form information collection. The purpose of the Medical Assessment Form is to collect standardized health information on unaccompanied children during evaluations with generalist medical providers, pediatricians, and other medical specialty providers.
In November 2023, ORR hired a Reproductive Health specialist who reviewed the Medical Assessment Form and recommended changes to the reproductive health history section and genito-urinary/reproductive diagnosis fields. ORR believes these changes will aid healthcare providers in performing a thorough assessment and creating an informed healthcare plan.
ORR would like to:
⢠replace the field âif unknown, months since LMP" with 2 options, âApproximateâ and âExactâ in the last menstrual period (LMP) field,
⢠rename the âCurrent contraceptive useâ field to âContraceptive useâ and add a specify field with examples,
⢠replace the field âPregnancy: Gravida ___ Parity ___; location & age of child(ren):â with âPregnancy historyâ and add discrete options to capture the number of each pregnancy outcome (e.g., vaginal deliveries, ectopic pregnancies),
⢠add a new free text field called âPregnancy/postpartum complicationsâ, and
⢠update several diagnoses under the Genito-urinary/Reproductive category in the Diagnosis and Plan section
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.
Dental Assessment Form - Recordkeeping Time