Information Collection

Medical Assessment Form (recordkeeping time - completed by medical provider)

IC 283303 under ICR 202610-0970-004 · OMB 0970-0466.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Medical Assessment Form Medical Assessment Form (recordkeeping time - completed by medical provider)	Form
1 Medical Assessment Form Medical Assessment Form_Clean_Updated Oct 21 2026.docx	Form
Dear Colleague Letter - Medical Assessment Form_Clean_Updated Oct 26 2026.docx Dear Colleague letter	IC Document

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Mandatory

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1				Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title: ORR Unaccompanied Children Bureau Administrative Program Records

FR Citation: 89 FR 100500

Number of Respondents: 150

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	23,808	23,808
Annual IC Time Burden (Hours)	5,714	5,714
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Dear Colleague letter		10/27/2026

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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