OMB control number
Medical Assessment Form and Dental Assessment Form
OMB 0970-0466 · HHS/ACF.
OMB 0970-0466
The Medical Assessment Form was approved by OMB on October 26, 2023, as part of the Medical Assessment Form and Dental Assessment Form information collection. The purpose of the Medical Assessment Form is to collect standardized health information on unaccompanied children during evaluations with generalist medical providers, pediatricians, and other medical specialty providers. The following two Administration for Children and Families (ACF) Office of Refugee Resettlement (ORR) information collections capture health data on children in ORR care: • Medical Assessment Form and Dental Assessment Form • Mental Health Assessment Form and Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness. ACF has implemented changes to update gender collected data to denote sex as a biological variable in current approved information collection requests to comply with recent presidential directives.
The latest form for Medical Assessment Form and Dental Assessment Form expires 2026-10-31 and is listed under ICR 202502-0970-013.
Latest Forms, Documents, and Supporting Material
Form 1 Serious Medical Prodcedure Request Form
public comment on Proposed Information Collection, Office of Refugee Resettlement (ORR) Unaccompanied Alien Child Health Forms (OMB #0970-0466).pdf
Serious Medical Procedure Request (recordkeeping time)All Historical Document Collections
OMB Details
Medical Assessment Form - Reporting Time for Pediatricians, General
Federal Enterprise Architecture: Community and Social Services - Social Services
| Form | Name | Electronic access | Type |
|---|---|---|---|
| Form 1 | Medical Assessment Form | Fillable Fileable | Form |
Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.