Supporting Statement A_Medical Assessment Form and Dental Assessment Form

Medical Assessment Form and Dental Assessment Form

OMB Information Collection Request

0970 - 0466

Supporting Statement Part A - Justification

August 2023

Submitted By:

Office of Refugee Resettlement

Administration for Children and Families

U.S. Department of Health and Human Services

Summary

The Administration for Children and Families (ACF) is requesting a three-year extension of approval for the Medical Assessment Form (formerly, the Initial Medical Exam Form and Supplemental Tuberculosis Screening Form) and Dental Assessment Form (formerly, the Dental Exam Form) (OMB #0970-0466, expiration 12/31/2023). Revisions are proposed to the currently approved forms as described in section A15.

1. Circumstances Making the Collection of Information Necessary

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.

Per ORR requirements, each child must receive an initial medical exam (IME) within 2 business days of admission to an ORR care provider program or temporary influx care facility (ICF). The IME satisfies Flores requirements which require a “complete medical examination, including a screening for infectious disease. See Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A). The purposes of the IME are to assess general health, administer vaccinations in keeping with U.S. standards (also required by Flores), identify health conditions that require further attention, and detect contagious diseases of public health importance, such as influenza or tuberculosis. The IME is performed by a licensed health care provider and comprised of a complete medical history and physical exam, risk- and age-based laboratory screenings, tuberculosis screenings and immunizations. Children who are in ORR custody 60 to 90 days after admission must receive an initial dental exam, or sooner if directed by state licensing requirements. Children who are in ORR care for an extended length of time may also require routine medical and dental well-child evaluations. In addition, children may be referred to a medical or dental specialist by their healthcare provider for acute or chronic conditions that require additional evaluation, or they may need emergent/urgent care services.

ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnoses, lab results, immunizations, and treatments are documented and included in the child’s discharge packet at the time of unification with their sponsor. ORR requires the Medical Assessment and Dental Assessment information collections to implement and maintain compliance with the Flores Settlement Agreement.

2. Purpose and Use of the Information Collection

The purpose of these instruments is to collect standardized health information on unaccompanied children during evaluations with generalist medical providers, pediatric and other medical specialty providers, and dental providers. Data collection for mental health-related visits, however, is conducted under a separate OMB-approved information collection: Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness (OMB #0970-0509¹).

The forms are to be used as worksheets for the specified healthcare providers to compile information that would otherwise have been collected during the evaluation Once completed, the forms are given to care provider program staff for data entry into ORR’s secure, electronic record system. Note, the forms are not completed by healthcare providers during emergency department visits, hospitalizations, or acute/rehab medical facility admissions as these types of evaluations are typically managed by multiple healthcare providers; care provider program staff glean the required data from health records and document in the electronic version of the form.

Data is used by ORR to monitor the health of unaccompanied children while in care, for case management of identified illnesses/conditions, and to ensure care provider program compliance with ORR requirements. ORR also requires documentation of all health-related services rendered (e.g., immunization records, lab results, imaging study reports, office notes) to provide oversight on complex/fragile cases, authorize additional diagnostic work-up and procedures, and verify data entered in ORR’s electronic record system. The collection of this information in a central location allows for continuity of care for transferred and readmitted children.

3. Use of Improved Information Technology and Burden Reduction

Currently, care provider program staff enter data from the forms into the “UC Portal” and upload the original forms and related documentation to the child’s electronic record. Fields in the UC Portal are designed to reduce data entry time and errors by utilizing dropdowns, checkbox options, business requirements, and system logic. The UC Portal also generates automated notifications to ORR on significant events (e.g., reportable infectious disease diagnoses). Data from the forms will be accessible to ORR and, in the event of a transfer, the new care provider program to ensure continuity of care.

ORR plans to procure a new secure electronic record system for capturing medical, mental health, dental and public health information in 2024. The new Medical and Dental Assessment Forms will be replicated, and historic data stored in the UC Portal will be migrated to the new system. In addition, the new system will collate and display critical health information (e.g., medications, allergies, pending health appointments) on the child’s summary page for ease of tracking and reference.

4. Efforts to Identify Duplication and Use of Similar Information

The information being collected by these instruments are not obtainable from other sources.

5. Impact on Small Businesses or Other Small Entities

The proposed information collection request does not impact small businesses or other small entities. This information collection primarily affects the operations of the federal government, particularly, ORR’s management of the care and custody of unaccompanied children.

6. Consequences of Collecting the Information Less Frequently

ORR mandates that the initial medical and dental exam data collections occur at a single time as part of the admission process. The IME is performed within 2 business days of admission; the initial dental exam is performed within 60 to 90 days of admission, or sooner if required by state regulations. Follow-up evaluations and specialist referrals occur as recommended by the healthcare provider. The forms are completed by the conclusion of the assessment and returned to care provider program staff who then enter the data into ORR’s electronic record system within 48 hours, or sooner if the evaluation was urgent/emergent. Performing the data collection less frequently would prohibit ORR from tracking, monitoring, and advising on medical and dental health issues in a timely manner and consequently, cause ORR to be in violation of the Flores Settlement Agreement.

7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5

This request fully complies with the regulation 5 CFR 1320.5.

8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency

In accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13) and Office of Management and Budget (OMB) regulations at 5 CFR Part 1320 (60 FR 44978, August 29, 1995), ACF published a notice in the Federal Register announcing the agency’s intention to request an OMB review of this information collection activity. This notice was published on June 1, 2023, Volume 88, Number 105, pages 35883-35884, and provided a sixty-day period for public comment. We did not receive comments.

During the form revision process, ORR consulted with community-based pediatric generalist and specialist healthcare providers, and subject matter experts at The Centers for Disease Control and Prevention (CDC) on appropriate content of medical evaluations for the unaccompanied children population and updated the Medical Assessment Form accordingly.

9. Explanation of Any Payment or Gift to Respondents

No monetary incentives or gifts are provided to respondents.

10. Assurance of Confidentiality Provided to Respondents

ORR established a system of records to ensure the level of confidentiality pursuant to the Privacy Act. 5 U.S.C. 552a. ORR’s system of records notice was titled “09-80-0321 ORR Division of Children's Services Records” and published on July 18, 2016, at 81 FR 46682.

Deidentified data is shared with stakeholders (e.g., Department of Health and Human Services leadership, Congress, the CDC) on an ad hoc basis several times a year. Examples of shared data include immunization rates, COVID-19 case numbers, and the number of children in isolation. Confidential information is only shared with relevant stakeholders for public health purposes (e.g., contact investigations of reportable infectious diseases).

11. Justification for Sensitive Questions

ORR collects sensitive health information on medical and social history, signs/symptoms, mental health status, lab results and diagnoses to monitor, counsel, and treat children as directed by the Flores Settlement Agreement. Health evaluations are performed in an opt-out manner where questions are asked, but children have the right to refuse to respond. Recorded information becomes part of the child’s health record and is viewable only to care provider program staff who are directly responsible for the child, ORR field-based program managers, and ORR federal staff. Children are provided with copies of their health records at the time of discharge from ORR custody with the expectation that collected information will be shared with their new healthcare providers.

12. Estimates of Annualized Burden Hours and Costs

The calculation of annual burden estimates is based on the following factors:

• The number of times these data are collected is dependent upon the number of unaccompanied children crossing over the U.S. border on an annual basis. Based on the average number of children entering the U.S. during fiscal years 2021 and 2022, ORR estimates that the number of children will be approximately 125,800 annually.

• ORR currently funds approximately 250 care provider programs and 1 ICF and expects to continue the trend of increasing capacity each year.

• All children receive an IME within 2 business days of admission.

• Children who are in ORR custody 60 to 90 days receive an initial dental exam and subsequent preventive dental care, as recommended by the dental provider. Approximately 5% of children in ORR custody in fiscal year 2022 received an initial dental exam.

• Estimates on the total number of responses per respondent annually were derived from UC Portal data from May 2022 through May 2023.

• Recordkeeping burden, including entering data from the forms into ORR’s secure electronic record system and uploading documentation of all health-related services rendered, will be incurred only by care provider program staff; healthcare providers will not incur recordkeeping burden for this collection. Care provider program staff will also complete the electronic version of the form from information gathered from health records; the paper version of the form is not completed during emergency department visits, hospitalizations, or acute/rehab medical facility admissions as these types of evaluations are typically managed by multiple healthcare providers.

• The cost to respondents was calculated using hourly wage data, accessed in May 2023, from the Bureau of Labor Statistics (BLS):

• The cost to general pediatrician respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Pediatricians, General [29-1221] and wage data from May 2022, which is $97.71 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $195.42. The estimate of annualized cost to respondents for hour burden is $195.42 times 55,440 hours or $10,834,084.80.

https://www.bls.gov/oes/current/oes291221.htm

• The cost to medical specialist respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Physicians, All Other [29-1229] and wage data from May 2022, which is $114.76 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $229.52. The estimate of annualized cost to respondents for hour burden is $229.52 times 3,630 hours or $833,157.60.

https://www.bls.gov/oes/current/oes291229.htm

• The cost to general dentist respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Dentists, General [29-1021] and wage data from May 2022, which is $82.83 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $165.66. The estimate of annualized cost to respondents for hour burden is $165.66 times 1,920 hours or $318,067.20. https://www.bls.gov/oes/current/oes291021.htm

• The cost to care provider program staff respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Child, Family, and School Social Workers in the industry of Other Residential Care Facilities [21-1021] and wage data from May 2022, which is $27.25 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $54.50. The estimate of annualized cost to respondents for hour burden is $54.50 times 99,825 hours or $5,440,462.50.

https://www.bls.gov/oes/current/oes211021.htm

Estimated Reporting Time

Information Collection Title	Respondent	Annual Number of Respondents	Number of Responses Per Respondent	Average Burden Hours Per Response	Annual Burden Hours	Average Hourly Wage	Total Annual Cost
Medical Assessment Form	Pediatricians, General	300	840	0.22	55,440	$195.42	$10,834,085
	Medical Specialist, General	750	22	0.22	3,630	$229.52	$833,158
Dental Assessment Form	Dentists	250	64	0.12	1,920	$165.66	$318,067
Estimated Annual Burden Total:					60,990	Estimated Annual Cost Total:	$11,985,310

Estimated Recordkeeping Time

Information Collection Title	Respondent	Annual Number of Respondents	Number of Responses Per Respondent	Average Burden Hours Per Response	Annual Burden Hours	Average Hourly Wage	Total Annual Cost
Medical Assessment Form completed by a medical professional	Care Provider Program Staff	500	537	0.33	88,605	$54.50	$4,828,973
Medical Assessment Form not completed by a medical professional (information obtained via health records)		500	100	0.17	8,500		$463,250
Dental Assessment Form		500	32	0.17	2,720		$148,240
Estimated Annual Burden Total:					99,825	Estimated Annual Cost Total:	$5,440,463

13. Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers

There are no other costs to respondents and record keepers.

14. Annualized Cost to the Federal Government

• Form Development and Implementation: The forms were developed by a GS-13, step 6-level public health analyst in the Boston area who spent approximately 100 hours revising the forms. Once ORR procures a new electronic medical record system in 2024, electronic versions of the form will be developed. It is estimated that development of the electronic versions will require 300 hours. To account for fringe benefits and overhead, the hourly rate for this position ($61.94) was multiplied by two for a total of $123.88. Therefore, the cost to create the paper and electronic versions of the form was/will be $49,552.

• Training and quality assurance:

• Training/Guidance documents: Documentation guidance is written by a GS-13, step 6-level public health analyst in the Boston area who spends approximately 120 hours annually performing this task. To account for fringe benefits and overhead, the hourly rate for this position ($61.94) was multiplied by two for a total of $123.88. Therefore, the annual cost to write documentation guidance will be $14,866.

• Trainings and quality assurance: ORR employs 8 contractors to train care provider staff on documentation of health data and to perform quality assurance checks on entered data. Collectively, the contractors spend approximately 7,488 hours annually completing these tasks. The hourly rate for this position, including fringe benefits and overhead is $84.07. Therefore, the annual cost to train staff on proper documentation and perform data quality assurance activities is $629,516.

• Data analysis: Data collected from the forms and entered into ORR’s electronic record system is analyzed by a GS-12, step 5-level IT Manager in the Washington DC area who spends approximately 936 hours annually performing this task. To account for fringe benefits and overhead, the hourly rate for this position ($51.15) was multiplied by two for a total of $102.30. Therefore, the annual cost to analyze the data collected on the Medical Assessment Form and Dental Assessment Form is $95,753.

It is estimated that the annual cost to the government for this information collection will be $789,687 over the next 3 years.

15. Explanation for Program Changes or Adjustments

The currently approved information collection includes an Initial Medical Exam Form and a Supplemental TB Screening Form. Data collection for all other medical evaluations is conducted on the Health Assessment Form under forms approved under OMB #0970-0509². This new request merges the medical data from the three forms into a single Medical Assessment Form that will be used during all evaluations with a mid-level, or higher medical professional (e.g., medical doctor, nurse practitioner), including the IME. This change will simplify and streamline the data collection process for healthcare providers as the same form will be used for every medical assessment regardless of the reason for the visit.

In addition, several changes were made to the Medical and Dental Assessment Forms including, 1) adding fields to the General Information section to capture information on translation services and purpose of visit, 2) enhancing the History and Physical Assessment section to obtain a more thorough health and social history, and 3) reformatting and building out several fields to clarify intent of current high-level specify fields. Other updates made solely to the Medical Assessment Form include the addition/revision of the physical and mental status exams, diagnoses, and lab testing requirements. These changes were made to ensure healthcare providers are performing complete physical and mental health exams and documenting diagnoses in a standardized manner. Adjustments were made to the lab testing requirements in accordance with the changes made to ORR’s IME requirements.

Lastly, instructional letters have been written for each respondent completing an Assessment Form that explain the purpose and data collection guidelines for each form (Attachments B and C). Adjustments have been made to burden estimates where applicable and burden estimates have been broken out to display burden more clearly for each type of respondent and activity.

16. Plans for Tabulation and Publication and Project Time Schedule

ORR does not plan to publish the results of these information collections. Portions of the data from the information collections may be included in public reports, however the primary purposes of the information collections are to allow ORR to identify and track illnesses and conditions that require monitoring, control, and follow-up, and to ensure that care provider programs and healthcare providers are complying with ORR requirements. These information collections are ongoing.

17. Reason(s) Display of OMB Expiration Date is Inappropriate

ORR intends to display the expiration date for OMB approval of the information collections on the instruments.

18. Exceptions to Certification for Paperwork Reduction Act Submissions

No exceptions are necessary for this information collection.

1 Note that concurrent with this request (2023), we are revising OMB #0970-0509 and as part of that update the title is changing from Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB to Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness

2 Note that concurrent with this request (2023), we are revising OMB #0970-0509 and as part of that update the title is changing from Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB to Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness