Supporting Statement A

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	Office of Refugee Resettlement (ORR) Unaccompanied Alien Children Health Forms


OMB Information Collection Request
0970 - 0466


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













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) Office of Refugee Resettlement (ORR) is requesting to move the Serious Medical Procedure Request (SMR) Form (OMB# 0970-0561, expiration date 12/31/2026) under the Medical Assessment Form and Dental Assessment Form (OMB# 0970-0466, expiration 10/31/2026) 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. 


    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). 

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 ORR’s electronic case management system. 

All non-emergent procedures performed under anesthesia or IV sedation require ORR approval. Before ORR’s 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.


    2. Purpose and Use of the Information Collection 
Data collected on the MAF and DAF allow ORR to ensure children are receiving appropriate healthcare services and to provide oversight of children with special healthcare needs. Data collection for mental health visits and onsite health interventions is conducted under a separate OMB-approved information collection: Mental Health Assessment and Onsite Health Intervention Forms (OMB #0970-0509). 

The MAF and DAF are used to capture a subset of the data collected during a comprehensive exam with a medical or dental healthcare provider, respectively. The MAF and DAF each have 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 with ORR care providers. The MAF and DAF are completed by the evaluating healthcare provider and submitted to care provider program staff by the conclusion of the visit. Care provider program staff enter the data into ORR’s electronic case management system. Although the MAF is not completed during emergency or urgent care visits, hospitalizations, follow-up immunization visits in the absence of a healthcare provider evaluation, or admissions to medical rehabilitation facilities, care providers are required to complete the electronic version of the MAF by extracting relevant data from health records. 

The purpose of the SMR Form is for ORR to collect standardized information on the risks and benefits of a recommended serious medical or dental procedure and use this information to make an informed decision on the necessity of the recommended procedure while the child is in ORR care. Once completed by the treating healthcare provider (e.g., surgeon), care provider program staff will transcribe the information and upload the form and supporting documentation into ORR’s secure, 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 forms into the “UAC Portal”, a secure electronic case management system, and upload all health records and ORR’s completed forms, when applicable, 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., hospitalizations). 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 forms will be digitized in the new system. In addition to capturing the data from the forms, the new application will collate and display critical health information (e.g., 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., healthcare providers not employed by the ORR care provider program) to directly enter their assessment 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 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. 


    6. Consequences of Collecting the Information Less Frequently 
Healthcare providers are required to complete the MAF and DAF by the conclusion of every scheduled evaluation. Documentation of medical and dental evaluations in ORR’s electronic case management system by care provider staff must occur within 48 hours of the evaluation or sooner if the evaluation was an emergency or urgent visit, or if the child was hospitalized or placed at a rehabilitation medical facility. The SMR form must be completed by the treating healthcare provider and submitted to care provider staff for entry into ORR’s electronic case management system within 2 business days. Collecting this information less frequently would jeopardize ORR’s ability to monitor the delivery of healthcare services to children in ORR care and provide timely approval for services, as applicable.  


    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 August 5, 2026 (91 FR 50549) and provided a sixty-day period for public comment. During the notice and comment period, we received two comments. 

Both commenters support continuity of care for children with special healthcare needs who are discharged from ORR for DHS-led repatriation; however, commenters felt that additional safeguards were needed to protect the children’s health info including:
    • Further restricting the type of diagnoses that will be shared (i.e., only active diagnoses that require management during travel) 
    • Clarifying when the data should be shared with DHS and who should receive the information
    • Providing a notice to the child, family, and legal representatives of the disclosure
    • Explicitly restricting health data use to medical care only — not enforcement, detention, or legal proceedings
    • Developing DHS data retention and access rules

	Comments are addressed in 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 of children 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 ill from DHS custody at an ORR facility and ORR was not notified in advance, or a child requires emergent/urgent healthcare services shortly after placement. 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 ORR custody.   
    • when a child with healthcare needs departs ORR custody for DHS-led repatriation. Data will be shared with the DHS Field Office Juvenile Coordinator (FOJC) when travel arrangements have been made. Data is not shared for immigration enforcement purposes. ORR care providers will share active diagnoses or concerns that require management during travel, 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 the MAF and DAF on medical and social history, signs/symptoms, physical exam findings, lab and imaging results, treatment plans and diagnoses to monitor, counsel, and treat children as directed by the Unaccompanied Children Program Foundational Rule. The SMR Form collects sensitive information in the form of diagnoses, procedure names, and clinical indications as ORR cannot decide on the necessity of a recommended procedure in the absence of this info. ORR does not ask for information of a sensitive nature beyond what is needed to provide services and oversight. 

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 accessible only to care provider program and ORR staff who are directly responsible for the care of 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 and ORR was not notified in advance, or when a child requires emergent/urgent healthcare services shortly after placement, and 2) continuity of care when a child with healthcare needs is discharged from ORR care for DHS-led 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 completion time for 9 healthcare providers during 105 visits across the three forms.
    • Estimates on the MAF and DAF annual number of responses per respondent were derived from data provided by ORR’s 3rd party underwriter, Point Comfort United, for the period of June 1, 2025 through December 31, 2025. Estimates on the SMR’s annual number of responses per respondent were based on the number of SMRs received by ORR February 1, 2025 through January 31st, 2026.
    • 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, is currently incurred only by care provider program staff; healthcare providers not employed by the care provider program will not incur recordkeeping burden for this collection.  

 
Estimated Cost to Respondents

The cost to respondents was calculated using hourly wage data, accessed in September 2026, from the Bureau of Labor Statistics (BLS):   
    • The cost to pediatrician respondents was calculated using the Bureau of Labor Statistics (BLS) job code for 29-1221 Pediatricians, General and wage data from May 2025, which is $101.98 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $203.96. U.S. BLS 29-1221 Pediatricians, General

    • The cost to medical specialist respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Physicians, All Other [29-1229] and wage data from May 2025, which is $125.98 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $251.96. U.S. BLS 29-1229 Physicians, All Other

    • The cost to general dentist respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Dentists, General [29-1021] and wage data from May 2025, which is $91.99 per hour. To account for fringe benefits and overhead the rate was multiplied by two which is $183.98. U.S. BLS 29-1021 Dentists, General

        ◦ The cost to surgeon respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Pediatric Surgeons [29-1243] and wage data from May 2025, which is $241.37 per hour. To account for fringe benefits and overhead, the rate was multiplied by two which is $482.74. U.S. BLS 29-1243 Pediatric Surgeons

    • 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
MAF
Pediatricians, General
150
104
0.134
2,090.4
$203.96
$426,357.98

Medical Specialist, General
300
27.4
0.137
1,126.1
$251.96
$283,742.23
DAF 
Dentists
150
124.4
0.05
933
$183.98
$171,653.34
SMR Form
Surgeons
150
0.67
0.17
17.1
$482.74
$8,254.85
Estimated Annual Burden:  
4,166.6
Estimated Annual Cost Total: 
$890,008.40




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
MAF completed by a medical provider
Care Provider Staff
150
158.72
0.24
5,713.92
$61.54
$351,634.64
MAF not completed by a medical provider (information obtained via health records)

150
22.08
0.33
1,092.96

$67, 260.76
DAF 

150
124.4
0.15
2,799

$172,250.46
SMR Form

150
0.67
0.08
8.04

$494.78
Estimated Annual Burden:  
9,613.92
-Estimated Annual Cost Total: 
$591,640.64



    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 

All forms - 
    • Form Digitization: A GS-14, step 4-level Health Scientist in the Boston area will be involved in the design and digitization of the forms into ORR’s new electronic health application. It is estimated that development of the electronic versions will require 250 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 forms will be $37,540.00. 
    • Training, guidance, and quality assurance: ORR employs 7 contractors as “Quality Assurance Specialists” to provide documentation-related trainings and written guidance to care provider program and ORR staff and to perform quality assurance activities. Collectively, the Quality Assurance Specialists spend approximately 3,510 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 $312,600.60. 
    • Data analysis: Data collected from the forms and entered into ORR’s electronic case management system is analyzed by a GS-13, step 4-level IT Manager in the Washington DC area who spends approximately 626 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 Medical Assessment, Dental Assessment, and SMR Forms is $80,365.88. 

SMR Form only - 
    • ORR Review:
    • Upon submission to ORR, the form is reviewed for completeness by an ORR Quality Assurance Specialist. The hourly rate for this position including fringe benefits and overhead is $89.06. It is estimated that the Quality Assurance Specialists will spend approximately 220 hours a year processing SMR request packets. Therefore, the annual cost to process the SMR request packet is $19,593.20.
    • The complete request packet will then be forwarded to an ORR Medical Officer to determine if the procedure/surgery while in ORR care is medically necessary. ORR’s Medical Officer team is comprised of a mix of healthcare professionals at the 14 and 15 GS-levels. To determine the hourly rate, an average was calculated based on the hourly wage of a GS-level 14 and 15 step 5 in the Washington DC area ($85.04). To account for fringe benefits and overhead, the average hourly rate was multiplied by two for a total of $170.08. It is estimated that the ORR Medical Officer will spend approximately 252.5 hours a year reviewing request packets. Therefore, the annual cost to review the SMR request packet is $42,945.20.
    • If the procedure is deemed necessary by the ORR Medical Officer, the SMR packet will be submitted to Division leadership personnel (GS-15, step 5-level in the Washington DC area) for final approval. To account for fringe benefits and overhead, the hourly rate for this position ($91.93) was multiplied by two for a total of $183.86. It is estimated that the ORR leadership staff member will spend approximately 30 hours a year reviewing request packets. Therefore, the annual cost to review and approve the SMR request packet is $5,515.80.

 
It is estimated that the annual cost to the government for this information collection is $473,534.01 over the next 3 years. 



    15. Explanation for Program Changes or Adjustments 

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.

The MAF and DAF would also be revised to:
    • reduce duplicate documentation and encourage form completion by only requiring completion of the History section on the DAF for the initial dental exam (IDE) and allowing healthcare providers the option of summarizing critical health information in the first two pages of the MAF instead of completing a third page for all scheduled visits except the initial medical exam (IME) and routine well-child visits.
    • improve compliance and care tracking by strengthening the disabilities and accommodations field and adding a field for all ordered and completed labs and imaging on the MAF.
    • improve data quality through clearer instructions by visit type, 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 Letters have also been updated to reflect these MAF and DAF changes. 
 
In addition, language was updated to expand the purposes of data to include sharing relevant health data captured on the MAF and DAF with DHS when a child in ORR custody with healthcare needs is discharged from ORR care for DHS-led 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.


    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.