Medical Assessment Form and
Dental Assessment Form
No
material or nonsubstantive change to a currently approved
collection
No
Regular
10/07/2024
Requested
Previously Approved
10/31/2026
10/31/2026
619,000
619,000
160,815
160,815
0
0
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. The following two Administration
for Children and Families (ACF) Office of Refugee Resettlement
(ORR) information collections capture health data on children in
ORR care: • Medical Assessment Form and Dental Assessment Form •
Mental Health Assessment Form and Public Health Investigation Form:
Active TB, and Public Health Investigation Form: Non-TB Illness.
ORR has recently identified a specific need to share data collected
on ORR’s health assessment forms that falls outside of the stated
limitations with the Department of Homeland Security (DHS). The
need to communicate with DHS occurs when a newly referred child
arrives at an ORR facility ill or requires emergent/urgent
healthcare services shortly after placement and ORR was not
notified in advance. For DHS to investigate the event, ORR must
share confidential and sensitive health information including the
child’s alien number, name, signs/symptoms, diagnoses, and date of
diagnosis. The goal of this data sharing effort is to identify
areas of potential improvement in delivery of healthcare services
and continuity of care for children transferred from DHS to HHS
custody. Currently, there is specific language in the Supporting
Statements describing limitations on data sharing that limits ORR’s
ability to fulfill this need. ORR has discussed the need to update
this language with OMB and as a result ORR published a notice in
the Federal Register (89 FR 54829) on July 2, 2024 announcing a
30-day period for the public to comment on the proposed changes. No
comments were received, and we are now submitting the updated
Supporting Statement A for final review and approval.
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.
Form 1 Dental Assessment Form - Recordkeeping Time
NonSub Change Request_0466 and 0509_FINAL_10.4.24.docx
30 Day FRN_Data Sharing Updates _0970-0466 and 0970-0509_7.2.24.pdf
Dental Assessment Form - Recordkeeping Time