U.S. Repatriation Program Forms

Forms and Documents

Document Name	Status
Form 1 Temporary Assistance Extension Request Form Form and Instruction	Modified
Form 1 State Request for Federal Support Form and Instruction	Modified
Form 1 Loan Waiver and Deferral Request Form Form and Instruction	Modified
Form 1 Non-emergency Monthly Financial Statement Form Form and Instruction	Modified
Form 1 Emergency and Group Repatriation Form and Instruction	Modified
Form 1 Refusal of Temporary Assistance Form and Instruction	Modified
Form 1 Privacy and Repayment Agreement Form and Instruction	Modified
Form 1 Emergency and Group Processing Form and Instruction	Modified
Supporting Statement A - 0970-0474 - Repatriation Forms.doc Supporting Statement A	2019-03-18

IC Document Collections

IC ID	Document Title	Status
218660	Temporary Assistance Extension Request Form Form and Instruction	Modified
218659	State Request for Federal Support Form and Instruction	Modified
218658	Loan Waiver and Deferral Request Form Form and Instruction	Modified
218657	Non-emergency Monthly Financial Statement Form Form and Instruction	Modified
218656	Emergency and Group Repatriation Form and Instruction	Modified
218655	Refusal of Temporary Assistance Form and Instruction	Modified
218654	Privacy and Repayment Agreement Form and Instruction	Modified
218653	Emergency and Group Processing Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 201903-0970-002
Status: Active	Previous ICR Reference No: 201510-0970-006
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: U.S. Repatriation Program Forms
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/29/2019
	Date Received in OIRA: 03/29/2019
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	36 Months From Approved	04/30/2019
Responses	51,524	0	51,524
Time Burden (Hours)	9,204	0	9,204
Cost Burden (Dollars)	0	0	0

---

Abstract: This information is being requested in order to carry out the functions of the U.S. Repatriation Program. This program is authorized by Section 1113 of the Social Security Act (42 U.S.C. § 1313) and the assistance provided to mentally ill repatriates found under 24 U.S.C. §§ 321 - 329. This program also provides services under emergency and group repatriations which are authorized under Section 1113 and by the extension of the Executive Order (E.O.) precedent, E.O. 12656 (53 CFR 47491). General program regulations are found under 45 CFR 211 & 212. These laws and regulations require HHS to obtain specific information to determine eligibility for HHS repatriation, to provide services to eligible repatriates, to reimburse states for services provided and to collect repatriation loans from repatriates. This collection of information was originally approved on March 4, 2016. This current request is for an extension with no changes to the data collection elements. Forms were updated to make minor grammatical edits and to update phone numbers and addresses to be current.

---

Authorizing Statute(s): US Code: 42 USC 1313 Name of Law: Social Security Act
   US Code: 24 USC 321-329 Name of Law: Hospitals and Asylums
   EO: EO 12656 Name/Subject of EO: Assignment of Emergency Preparedness Responsibilities
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 739	01/31/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 11982	03/29/2019
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Temporary Assistance Extension Request Form	1	Temporary Assistance Extension Request Form
Emergency and Group Processing	1	Emergency and Group Processing Form
Privacy and Repayment Agreement	1	Privacy and Repayment Agreement Form
Refusal of Temporary Assistance	1	Refusal of Temporary Assistance Form
Emergency and Group Repatriation	1	Emergency Repatriation Financial Form
Loan Waiver and Deferral Request Form	1	Loan Waiver and Deferral Request
State Request for Federal Support	1	State Request for Federal Support Form
Non-emergency Monthly Financial Statement Form	1	Non-emergency Monthly Financial Statement Form

---

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	51,524	51,524	0	0	0	0
Annual Time Burden (Hours)	9,204	9,204	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:

---

Annual Cost to Federal Government: $40,708

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.     No

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

---

Common Form ICR:  No

---

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: 03/29/2019

---