Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness
Reinstatement with change of a previously approved collection
No
Regular
10/20/2026
table that charts list comparision
Requested
Previously Approved
36 Months From Approved
102,050
0
8,595
0
0
0
The Mental Health Assessment and Onsite Health Intervention Forms allow ORR to ensure children are receiving appropriate healthcare services and to provide oversight of children with special healthcare needs. Data collection for medical and dental visits and serious medical procedure requests is conducted under a separate OMB-approved information collection: Office of Refugee Resettlement (ORR) Unaccompanied Alien Child Health Forms (OMB #0970-0466 ).
The MHAF is used to capture a subset of the data collected during a comprehensive exam with a mental health professional (e.g., psychiatrist, psychiatric nurse practitioner or physician assistant, licensed psychologist, community-based licensed social worker). The MHAF has a corresponding âDear Colleagueâ letter that explains the purpose of the data collection, provides guidance on documentation, and outlines ORR requirements on sharing health records. The MHAF is completed by the evaluating mental health professional and submitted to care provider program staff by the conclusion of the visit. Care provider program staff then enter the data into ORRâs electronic case management system. Although the MHAF is not completed during emergency or urgent care visits, hospitalizations, or admissions to out-of-network facilities (e.g., residential treatment center), care providers are required to complete the electronic version of the MHAF by extracting relevant data from health records.
The OHIF is used to capture the details of a triage event or implementation of a medication-based standing order for an unaccompanied alien child. All healthcare concerns (e.g., fever, reported history of seizures, challenges with activities of daily living such as walking or eating, exposure to varicella) must be triaged in-person or remotely by a licensed healthcare professional within 2 hours of report/observation. The OHIF is completed by care provider program staff and entered into ORRâs electronic case management system.
Data is used by ORR to monitor and support the health of unaccompanied alien children while in care, for case management of identified illnesses/conditions, and to ensure care provider compliance with ORR requirements. ORR also requires documentation of all health-related services rendered (e.g., office notes, lab results, imaging study reports) to provide oversight on children with special healthcare needs, authorize additional diagnostic work-up and procedures, and verify data entered in ORRâs electronic case management system. The collection of this information in an electronic case management system allows for continuity of care for transferred and readmitted children.
The proposed restructuring and revisions will improve transparency, lessen burden, improve data quality, and ensure alignment with Office of Refugee Resettlement (ORR) requirements.
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.
Mental Health Assessment Form - Recordkeeping Time if obtained via health records