Medical Assessment Form and Dental Assessment Form
Revision of a currently approved collection
No
Regular
10/27/2026
table that charts list comparision
Requested
Previously Approved
36 Months From Approved
10/31/2026
88,462
619,000
13,780
160,815
0
0
The Administration for Children and Families (ACF) Office of Refugee Resettlement (ORR) is requesting to move the Serious Medical Procedure Request (SMR) Form (OMB#â¯0970-0561, expiration date 12/31/2026) under theâ¯Medical Assessment Form and Dental Assessment Formâ¯(OMB# 0970-0466, expirationâ¯10/31/2026)â¯information collection and update the title of OMB# 0970-0466 to Office of Refugee Resettlement (ORR) Unaccompanied Alien Child Health Forms. Revisions are proposed to the forms. 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 Medical Assessment Form (MAF) and Dental Assessment Form (DAF) with the Department of Homeland Security (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.â¯
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).
Health care services received by children in ORR custody include medical and dental baseline exams, routine well-child checks, preventive dental care, counseling services, sick visits, and urgent and emergency care. Care provider staff are expected to implement all treatment plans (e.g., referrals to specialists, procedures, accommodation for physical or mental impairments that impact daily living activities) as directed by the evaluating healthcare provider. ORR requires care providers to document the delivery of healthcare services and maintain health records on every child in ORRâs electronic case management system.
All non-emergent procedures performed under anesthesia or IV sedation require ORR approval. Before ORRâs medical professionals can make an informed decision, the treating healthcare provider (e.g., surgeon) must submit information on the procedure (e.g., name, clinical indication, risks, benefits, timeframe), post-operative care requirements (e.g., restrictions, care plan, travel clearance), and consent and assent (e.g., names, dates). ORR approval is not required for emergency-related procedures including procedures recommended during hospitalization.
Upon discharge, all children must receive copies of their health records to inform continuity of care with subsequent healthcare providers. ORR requires the MAF, DAF and SMR Form to implement and maintain compliance with the Unaccompanied Children Program Foundational Rule, 45 CFR Part 410.
US Code:
6 USC 279
Name of Law: Homeland Security Act (HSA)
ORR is proposing the incorporation of the SMR Form currently approved under OMB # 0970-0561 into the OMB #0970-0466 information collection and changing the title to Office of Refugee Resettlement (ORR) Unaccompanied Alien Child Health Forms to group forms with a similar purpose together. Other changes to the SMR form include the removal of the first page that was completed by care provider staff, clarifying the purpose of the form in the instructions, and revising fields to reduce redundancy and enhance data quality and healthcare provider response.
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.
Serious Medical Procedure Request (recordkeeping time)