Supporting Statement A

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Mental Health Assessment Form and Onsite Health Interventionn Form


OMB Information Collection Request
0970 - 0509


Supporting Statement Part A - Justification
October 2026
Type of Request: Reinstatement













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 reinstatement with changes to this information collection under OMB #0970-0509 (formerly, Public Health Investigation Form: Active TB and Public Health Investigation Form: Non-TB Illness). This includes updates to both the Mental Health Assessment Form (MHAF) and the Onsite Health Intervention Form (OHIF). Changes include updates to streamline and strengthen health documentation, reduce duplicate documentation, improve compliance and care tracking, and improve data quality. Additionally, information about sharing relevant health data captured on the MHAF with DHS in specific scenarios has been expanded. See section A15 for additional details on overall changes and section A10 for updated language about sharing data.


    1. Circumstances Making the Collection of Information Necessary 
The ACF Office of Refugee Resettlement (ORR) places unaccompanied alien children in their custody in care provider programs until unification with a qualified sponsor. Care provider programs are required to ensure children receive the appropriate medical, mental health and dental services per the Unaccompanied Children Program Foundational Rule, 45 CFR Part 410 (https://www.ecfr.gov/current/title-45/subtitle-B/chapter-IV/part-410?toc=1 ).

While in care at a care provider program, children meet with onsite mental health therapists on a regular basis. If a child is identified by an onsite therapist or other evaluating healthcare providers as potentially having a more serious mental health condition, they are referred to a licensed mental health professional. Care provider program staff are expected to implement all recommended treatment plans (e.g., referrals to specialists, medication administration, accommodation for mental impairments that impact daily living activities) as directed by the evaluating healthcare provider. 

Care provider program staff are also expected to respond to reported or observed non-emergency healthcare concerns (including exposures to specific reportable communicable illnesses) through triage with a licensed healthcare professional, or administration of over-the-counter medications as indicated by the child’s primary healthcare provider’s standing orders. 

ORR requires care providers to document the delivery of healthcare services and maintain health records on every child in ORR’s electronic case management system. Upon discharge, all children receive copies of their health records to inform continuity of care with subsequent healthcare providers. ORR requires the MHAF and OHIF to implement and maintain compliance with the Unaccompanied Children Program Foundational Rule, 45 CFR Part 410.

    2. Purpose and Use of the Information Collection 
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 #0970-04661). 

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 “Dear Colleague” 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 ORR’s 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 ORR’s 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 ORR’s 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. 

    3. Use of Improved Information Technology and Burden Reduction 
Currently, care provider program staff enter data from the MHAF and OHIF into the “UAC Portal”, a secure electronic case management system, and upload the original forms and all health records to the child’s health profile. Fields in the UAC Portal are designed to reduce data entry time and errors by utilizing dropdowns, checkbox options, and system logic. The UAC Portal also generates automated notifications to ORR on significant events (e.g., admissions to out-of-network residential treatment centers). Data from the forms is accessible to ORR and, in the event of a transfer, the new care provider program to ensure continuity of care. To protect health information, health data archives 45 days after a child is transferred or discharged from a care provider program.

The Health Tab in the UAC Portal will be replaced with a new health application by the end of 2026. The revised MHAF and OHIF will be digitized in the new system. The new application will collate and display critical health information (e.g., current medications, allergies, pending health appointments) on the child’s summary page for tracking and reference purposes. This same information will be used to auto-populate a health-related discharge summary form to provide children and sponsors with easy access to health info after release from ORR care. Although it won’t be part of the initial release, ORR may develop functionality to allow community-based healthcare providers (i.e., not employed by the ORR care provider program) to directly enter their evaluation findings into ORR’s new electronic case management system.


    4. Efforts to Identify Duplication and Use of Similar Information 
The information being collected by these instruments is not obtainable from other sources.

    5. Impact on Small Businesses or Other Small Entities 
Some MHAF respondents may own or be part of a small business. The burden on this information collection has been reduced as much as possible while still providing ORR with the information needed to ensure children are receiving the appropriate healthcare services while in ORR care. The OHIF is only completed by ORR-funded care provider programs.

    6. Consequences of Collecting the Information Less Frequently 
Healthcare providers and care provider program staff are required to complete ORR’s form by the conclusion of every scheduled evaluation and intervention, respectively. Documentation of mental health evaluations in ORR’s electronic case management system must occur within 48 hours of the evaluation or sooner if the evaluation was an emergency or crisis center visit, admissions to an out-of-network residential treatment center, partial hospital programs (PHP) or intensive outpatient programs (IOP), or psychiatric hospitalizations. OHIF documentation must occur within 48 hours of the intervention. Collecting this information less frequently would jeopardize ORR’s ability to monitor the delivery of healthcare services to children in ORR care. 

    7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5 
The Unaccompanied Children Program Foundational Rule, 45 CFR § 410.1307 Healthcare services, requires ORR to ensure that all children in ORR custody are provided with routine medical and dental care; access to medical services requiring heightened ORR involvement; family planning services; and emergency healthcare services. To comply with this regulation, ORR must collect this information at the conclusion of every health evaluation/intervention.

    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 July 27, 2026 (91 FR 46935) and provided a sixty-day period for public comment. During the notice and comment period, 4 comments were received. Comments addressed the following concerns:
    • Increased burden and potential documentation errors by not allowing the treating healthcare provider to bypass completion of the paper form and document directly into ORR’s electronic case management system. (Addressed in A3)
    • Clarifying the process by ORR care providers in obtaining consent from the child to share mental health information with DHS. (Addressed in A10)
    • A child is not able to provide consent regarding the sharing of their mental health information without the presence of an adult (Addressed in A10)
    • Unknown DHS processes for managing mental health information shared by ORR (Addressed in A10)
A lack of safeguards to prevent the expanded sharing of mental health information from negatively affecting the child. (Addressed in A10)
Based on the received comments, ORR Policy was consulted regarding consent processes when sharing health information with DHS and updates were made to A10.  

    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 
Deidentified data is shared with stakeholders (e.g., Department of Health and Human Services leadership, Congress, The Centers for Disease Control and Prevention) on an ad hoc basis several times a year. Examples of shared data include the number of children taking psychotropic medications and the number exposed to specific reportable communicable diseases.   
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, titled 09-80-0321 ORR Unaccompanied Children Bureau Administrative Program Records, was published on December 12, 2024 at 89 FR 100500.   
For the following operational purposes, the specific listed health information is shared with relevant stakeholders: 
    • public health reasons (e.g., contact investigations, exposure notifications). 
    • when a newly referred child arrives from the Department of Homeland Security (DHS) custody at an ORR facility and requires emergent/urgent healthcare services shortly after placement, and ORR was not notified in advance. In this circumstance, ORR notifies DHS and provides the child’s alien number, name, signs/symptoms, diagnoses, and date of diagnosis, to facilitate continuity of health care for children transferred from DHS to HHS custody.  
    • when a child with healthcare needs is transferred to DHS custody for repatriation purposes, ORR care providers will share active diagnoses or concerns with ongoing treatment plans, allergies, current medications and dosages, isolation/quarantine requirements, and health-related accommodations (including durable medical equipment needs) and travel restrictions. The purpose of sharing this data is to ensure children receive healthcare services and accommodation as indicated by their treating healthcare providers. 
UAC Bureau Policy Guide Section 5.9.2 provides that where medical or mental health records are requested for reasons other than the provision of services, ORR requires the authorizing signature and consent of the child or the child’s caregiver (parent/legal guardian or sponsor). If the child’s caregiver (parent/legal guardian or sponsor) is unable to provide consent (i.e., child is orphaned, parent/legal guardian cannot be located), ORR may provide consent for the release of medical or mental health records if the request is in the best interests of the child. Additionally, care providers must follow applicable state laws regarding consent for release of medical or mental health records.


    11. Justification for Sensitive Questions  
ORR collects sensitive health information on medical and social history, signs/symptoms, mental health status, lab results, treatment plans and diagnoses to monitor, counsel, and treat children as directed by the Unaccompanied Children Program Foundational Rule. Health evaluations are performed in an opt-out manner where children have the right to refuse to respond to questions. Recorded information becomes part of the child’s health record and is viewable only to care provider program and ORR staff who are directly responsible for the child and ORR headquarters staff. Sensitive health information may be shared with DHS for the purposes of 1) investigation 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, and 2) continuity of care when a child with healthcare needs is transferred from ORR to DHS custody for repatriation. 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 
Estimated Burden Hours
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 alien children crossing over the U.S. border or being apprehended internally within the U.S. on an annual basis. Based on the number of children admitted into ORR care between June 1, 2025, through May 31, 2026, ORR estimates that the number of children will be approximately 4,000 annually. 
    • ORR currently funds approximately 150 care provider programs and expects that number to hold steady for each year. 
    • Time per response for each form was calculated using the average time for mental health professionals to document 5 evaluations on the MHAF and for care provider program staff to document 4 interventions on the OHIF.
    • Estimates on the annual number of responses per respondent were derived from data provided by ORR’s 3rd party underwriter, Point Comfort United, for the time period of June 1, 2025 through December 31, 2025.
    • Recordkeeping burden, including entering data from the forms into ORR’s secure electronic case management 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. 

Estimated Cost to Respondents
The cost to respondents was calculated using hourly wage data, accessed in August 2026, from the Bureau of Labor Statistics (BLS):  
    • The cost to mental health professional respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Psychiatrists, All Other [29-1223] and wage data from May 2025, which is $129.78 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $259.56. U.S BLS 29-1223 Psychiatrists
    • 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 2025, which is $30.77 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $61.54. U.S. BLS 21-1021 Child, Family, and School Social Workers


Information Collection Title
Respondent
Total Number of Respondents
Annual Number of Responses Per Respondent
Average Burden Hours Per Response
Annual Burden Hours
Average Hourly Wage
Total Annual Cost
MHAF
Mental Health Professionals
250
9.8
0.13
318.5
$259.56
$82,669.86
OHIF
Care Provider Program Staff
150
321.6
0.09
4,341.6
$61.54
$267,182.06
Estimated Annual Burden Total:  
4,660.1
Estimated Annual Cost Total:
$349,851.92

Estimated Recordkeeping Time for Respondents
Information Collection Title
Respondent
Total Number of Respondents
Annual Number of Responses Per Respondent
Average Burden Hours Per Response
Annual Burden Hours
Average Hourly Wage
Total Annual Cost
MHAF completed by a mental health professional
Care Provider Program Staff
150
16.4
0.17
418.2
$61.54
$25,736.03
MHAF not completed by a mental health professional (information obtained via health records)

150
4.4
0.21
138.6

$8,529.44
OHIF

150
321.6
0.07
3,376.8

$207,808.27
Estimated Annual Burden Total:  
3,933.6
Estimated Annual Cost Total:
$242,073.74


    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 Digitization: The forms will be digitized and built into ORR’s new electronic health application by a GS-14, step 4-level Health Scientist in the Boston area. It is estimated that development of the electronic versions will require 200 hours. To account for fringe benefits and overhead, the hourly rate for this position ($75.08) was multiplied by two for a total of $150.16. Therefore, the one-time cost to develop electronic versions of the form will be $30,032.00.
    • Training, guidance, and quality assurance: ORR employs 7 contractors to provide documentation-related trainings and written guidance to care provider program and ORR staff and to perform quality assurance activities. Collectively, the contractors spend approximately 1,890 hours annually completing these tasks. The hourly rate for this position including fringe benefits and overhead is $89.06. Therefore, the annual cost to train staff on proper documentation and perform data quality assurance activities is $168,323.40.
    • Data analysis: Data collected from the forms and entered into ORR’s electronic data record system is analyzed by a GS-13, step 4-level IT Manager in the Washington DC area who spends approximately 434 hours annually performing this task. To account for fringe benefits and overhead, the hourly rate for this position ($64.19) was multiplied by two for a total of $128.38. Therefore, the annual cost to analyze the data collected on the Mental Health Assessment Form and Public Health Investigation Forms is $55,716.92.

It is estimated that the annual cost to the government for this information collection is $234,050.99 over the next 3 years.

    15. Explanation for Program Changes or Adjustments 
ORR is proposing updates to streamline and strengthen health documentation by combining the two Public Health Investigation Forms into the single expanded OHIF that would cover quarantine for communicable disease exposures, triage with a licensed healthcare professionals, and implementation of medication-related standing orders. The MHAF would also be revised to:
    • reduce duplicate documentation by removing the History section requirement for follow-up mental health visits,
    • improve compliance and care tracking by strengthening the disabilities and accommodations field and adding a field for all ordered or completed labs and imaging, and
    • improve data quality through clearer instructions by visit type, standardized options for findings outside of normal limits for the mental status exam, expanding the types of substances that may be used, a healthcare provider acknowledgement and signature section authorizing record sharing with ORR, replacement of fixed diagnosis choices with free-text fields, and broader field reformatting.

The related Dear Colleague Letter has also been updated to reflect these MHAF changes.

In addition, language was updated to expand the purposes of data to include sharing relevant health data captured on the MHAF with DHS when a child in ORR custody has healthcare needs and is identified by DHS for repatriation. See A10 for a list of shared information. The purpose of sharing this data is to ensure children receive healthcare services and accommodation as recommended by their treating healthcare providers. Prior to sharing mental health information with DHS, ORR will request consent from the child.

    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, but the primary purpose of the information collections is 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.