Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB

OMB 0970-0509

OMB 0970-0509

ACF is requesting an extension of the information collection previously approved under emergency clearance in March 2020. Pursuant to Exhibit 1, part A.2 of the Flores Settlement Agreement (Jenny Lisette Flores, et al., v. Janet Reno, Attorney General of the United States, et al., Case No. CV 85-4544-RJK (C.D. Cal. 1996), the Administration for Children and Families’ Office of Refugee Resettlement (ORR), on behalf of the Department of Health and Human Services (DHHS), is directed to provide unaccompanied children in their custody with medical, mental health, and dental care until reunification with a qualified sponsor. Unaccompanied minors in ORR custody are placed in grantee-operated licensed care provider facilities that arrange for appropriate emergent, routine and as-needed healthcare as directed by ORR, including “sick visits”, follow-up immunizations, urgent healthcare, and family planning services. Initial medical and dental and routine dental care are also required services for minors in ORR custody (OMB #0970-0466). ORR requires grantees to maintain records on each child to ensure that health-related evaluations, diagnosed conditions/illnesses, immunizations, and treatments are documented and included in the child’s discharge packet at the time of reunification. ORR requires the Health Assessment and Public Health Investigation information collections to implement and maintain compliance with the Flores Settlement Agreement.

The latest form for Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB expires 2023-12-31 and can be found here.

OMB Details

Health Assessment Form

Federal Enterprise Architecture: Community and Social Services - Social Services

Form 1Health Assessment Form Fillable PrintableForm

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