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	Unchanged	Repair queued
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Traditional Chinese	Form and Instruction	Unchanged	Repair queued
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Spanish	Form and Instruction	Unchanged	Repair queued
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Russian	Form and Instruction	Unchanged	Repair queued
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - French	Form and Instruction	Unchanged	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support - Arabic	Form and Instruction	Unchanged	Available
Form RR-08 Emergency Repatriation Request for Cost Approval and Federal Support	Form and Instruction	Unchanged	Repair queued
Form RR-07 Temporary Assistance Extension Request - Traditional Chinese	Form and Instruction	Unchanged	Repair queued
Form RR-07 Temporary Assistance Extension Request - Spanish	Form and Instruction	Unchanged	Repair queued
Form RR-07 Temporary Assistance Extension Request - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-07 Temporary Assistance Extension Request - Russian	Form and Instruction	Unchanged	Available
Form RR-07 Temporary Assistance Extension Request - French	Form and Instruction	Unchanged	Available
Form RR-07 Temporary Assistance Extension Request - Arabic	Form and Instruction	Unchanged	Repair queued
Form RR-07 Temporary Assistance Extension Request	Form and Instruction	Unchanged	Repair queued
Form RR-06 Refusal of Temporary Assistance - Traditional Chinese	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance - Spanish	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance - Russian	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance - French	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance - Arabic	Form and Instruction	Unchanged	Available
Form RR-06 Refusal of Temporary Assistance	Form and Instruction	Unchanged	Available
Form RR-05 Repatriation Repayment and Privacy Agreement	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - Traditional Chinese	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - Spanish	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - Russian	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - French	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request - Arabic	Form and Instruction	Unchanged	Available
Form RR-04 Routine Repatriation Reimbursement Request	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - Traditional Chinese	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - Spanish	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - Russian	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - French	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application - Arabic	Form and Instruction	Unchanged	Available
Form RR-03 Loan Waiver and Deferral Application	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Traditional Chinese	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Spanish	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Simplified Chinese	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Russian	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - French	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request - Arabic	Form and Instruction	Unchanged	Available
Form RR-02 Emergency Repatriation Reimbursement Request	Form and Instruction	Unchanged	Available
Form RR-01 Emergency Repatriation Eligibility Application	Form and Instruction	Unchanged	Available
NonSub Change Request - Correct SSA for 0970-0474.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2026-02-17	Repair queued
NonSub Change Request - Compliance Repat - 10Feb2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-02-10	Repair queued
Supporting Statement A - OHSEPR Repat Forms PTE TTA_0970-0474_CLEAN_Nov152023_Passback update Jan 2024_EO Up.docx	Supporting Statement A	Uploaded 2026-02-17	Repair queued

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 202602-0970-008
Status: Active	Previous ICR Reference No: 202502-0970-024
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: U.S. Repatriation Program Forms
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/19/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/17/2026
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2027	01/31/2027	01/31/2027
Responses	5,140	0	5,140
Time Burden (Hours)	1,470	0	1,470
Cost Burden (Dollars)	0	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. In 2025, ACF submitted updates to forms under this collection in response to new Executive Orders. Through that process, OMB requested minor edits to the SSA to align with the updates to the form. Through that revision process the incorrect SSA was inadvertently updated and sent for upload. ACF would like to replace the currently uploaded SSA with the correct version. The correct version matches the data entered in ROCIS in terms of burden estimates and forms approved.

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Authorizing Statute(s): US Code: 24 USC 321-329 Name of Law: Hospitals and Asylums
   US Code: 42 USC 1313 Name of Law: Social Security Act
   EO: EO 12656 Name/Subject of EO: Assignment of Emergency Preparedness Responsibilities
  

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	Emergency Repatriation Eligibility Application
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	Repatriation Repayment and Privacy Agreement
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 Approved	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	5,140	0	0	0	0
Annual Time Burden (Hours)	1,470	1,470	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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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: 02/17/2026

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