Initial Medical Exam Form and Initial Dental Exam Form

OMB Control No: 0970-0466	ICR Reference No: 201809-0970-006
Status: Historical Active	Previous ICR Reference No: 201508-0970-003
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Initial Medical Exam Form and Initial Dental Exam Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 05/28/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/21/2018
Terms of Clearance: We appreciate ACF's agreement to the terms of clearance. Approval of the expanded collection of medical information is limited to the following uses: •To provide oversight of all medical services delivered to unaccompanied children and those children with special health care needs, including approval of requested procedures, labs, and treatment plans. •To provide new healthcare providers with relevant health information in the event of a transfer, referral, or reunification of unaccompanied children who require additional follow-up and care. •To provide copies of all health-related records to unaccompanied children and their sponsors at discharge. •To provide federal and state stakeholders with relevant lab/imaging information during public health investigations.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2022	36 Months From Approved	05/31/2019
Responses	49,050	0	44,550
Time Burden (Hours)	14,040	0	10,773
Cost Burden (Dollars)	0	0	0

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Abstract: 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, and dental care until reunification with a qualified sponsor. Upon admission into a licensed care provider program, all children are required to receive a complete medical examination including screening for infectious diseases and immunizations recommended by the U.S. Public Health Service (PHS), the Center for Disease Control and Prevention. If children are still in ORR custody 70 to 90 days after admission, they are required to receive an initial dental exam. Additional required services include routine medical and dental care, family planning, and emergency health care.

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Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores Agreement

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12000	03/23/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 45934	09/11/2018
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

IC Title Form No. Form Name Initial Medical Exam Form 1, 1, 1, 1 Initial Medical Exam Form ,   Appendix A Initial Dental Exam Form 1 Initial Dental Exam Form

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ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	49,050	44,550	0	4,500	0	0
Annual Time Burden (Hours)	14,040	10,773	0	3,267	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: Data element were added.

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Annual Cost to Federal Government: $23,268

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

Agency Contact: Robert Sargis 202 690-7275 [email protected]

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Common Form ICR:  No

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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:
		(a) It is necessary for the proper performance of agency functions;
		(b) It avoids unnecessary duplication;
		(c) It reduces burden on small entities;
		(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;
		(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;
		(f) It indicates the retention periods for recordkeeping requirements;
		(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:
			(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;
		(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.
		(i) It uses effective and efficient statistical survey methodology (if applicable); and
		(j) It makes appropriate use of information technology.
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.
Certification Date: 09/21/2018

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