Medical Assessment Form and Dental Assessment Form

Forms and Documents

Document Name	Status
Form 1 Dental Assessment Form - Recordkeeping Time Form	Modified
Form 1 Medical Assessment Form - Recordkeeping Time (information obtained via health records) Form	Modified
Form 1 Medical Assessment Form - Recordkeeping Time (completed by a medical professional) Form	Modified
Form 1 Medical Assessment Form - Reporting Time for Medical Specialist, General Form	Modified
Form 1 Dental Assessment Form - Reporting Time Form	Unchanged
Form 1 Medical Assessment Form - Reporting Time for Pediatricians, General Form	Modified
NonSub Change - Update to ACF ICs - Protecting Women EO - Submission 2.10.25.docx Justification for No Material/Nonsubstantive Change	2025-02-10
NonSub Change Request_0466 and 0509_FINAL_10.4.24.docx Justification for No Material/Nonsubstantive Change	2024-10-04
30 Day FRN_Data Sharing Updates _0970-0466 and 0970-0509_7.2.24.pdf Supplementary Document	2024-10-04
NonSub Change Request_Medical Assessment Form_0970-0466.docx Justification for No Material/Nonsubstantive Change	2023-12-05
Attachment C_Dental Assessment Form Instructional Letter for Dental Providers.docx Supplementary Document	2023-08-02
Attachment B_Medical Assessment Form Instructional Letter for Medical Providers.docx Supplementary Document	2023-08-02
Supporting Statement A_Medical Assessment Form and Dental Assessment Form_Clean.docx Supporting Statement A	2024-10-04
Attachment A_Flores Agreement.docx Supplementary Document	2023-08-02

IC Document Collections

IC ID	Document Title	Status
261420	Dental Assessment Form - Recordkeeping Time Form	Modified
261419	Medical Assessment Form - Recordkeeping Time (information obtained via health records) Form	Modified
261416	Medical Assessment Form - Recordkeeping Time (completed by a medical professional) Form	Modified
261414	Medical Assessment Form - Reporting Time for Medical Specialist, General Form	Modified
217789	Dental Assessment Form - Reporting Time Form	Unchanged
217788	Medical Assessment Form - Reporting Time for Pediatricians, General Form	Modified

ICR Details

OMB Control No: 0970-0466	ICR Reference No: 202502-0970-013
Status: Received in OIRA	Previous ICR Reference No: 202410-0970-004
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Medical Assessment Form and Dental Assessment Form
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 02/15/2025

	Requested	Previously Approved
Expiration Date	10/31/2026	10/31/2026
Responses	619,000	619,000
Time Burden (Hours)	160,815	160,815
Cost Burden (Dollars)	0	0

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Abstract: 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.

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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:
	88 FR 35883	06/01/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 52166	08/07/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Dental Assessment Form - Recordkeeping Time	1	Dental Assessment Form
Dental Assessment Form - Reporting Time	1	Dental Assessment Form
Medical Assessment Form - Recordkeeping Time (completed by a medical professional)	1	Medical Assessment Form
Medical Assessment Form - Recordkeeping Time (information obtained via health records)	1	Medical Assessment Form
Medical Assessment Form - Reporting Time for Medical Specialist, General	1	Medical Assessment Form
Medical Assessment Form - Reporting Time for Pediatricians, General	1	Medical Assessment Form

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ICR Summary of Burden

	Total Request	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	619,000	619,000	0	0	0	0
Annual Time Burden (Hours)	160,815	160,815	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $789,687

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? Yes

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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: 02/15/2025

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