U.S. Repatriation Program Forms

Forms and Documents

Document Name	Status
Form 1 Emergency Repatriation Request for Cost Approval and Federal Support Form and Instruction	Modified
Form 1 Temporary Assistance Extension Request Form and Instruction	Modified
Form 1 Refusal of Temporary Assistance Form and Instruction	Modified
Form 1 Repatriation Repayment and Privacy Agreement Form and Instruction	Modified
Form 1 Routine Repatriation Reimbursement Request Form and Instruction	Modified
Form 1 Loan Waiver and Deferral Application Form and Instruction	Modified
Form 1 Emergency Repatriation Reimbursement Request Form and Instruction	Modified
Form 1 Emergency Repatriation Eligibility Application Form and Instruction	Modified
Supporting Statement A - OHSEPR Repatriation Revision v3.docx Supporting Statement A	2022-04-07

IC Document Collections

IC ID	Document Title	Status
218660	Emergency Repatriation Request for Cost Approval and Federal Support Form and Instruction	Modified
218659	Temporary Assistance Extension Request Form and Instruction	Modified
218658	Refusal of Temporary Assistance Form and Instruction	Modified
218657	Repatriation Repayment and Privacy Agreement Form and Instruction	Modified
218656	Routine Repatriation Reimbursement Request Form and Instruction	Modified
218655	Loan Waiver and Deferral Application Form and Instruction	Modified
218654	Emergency Repatriation Reimbursement Request Form and Instruction	Modified
218653	Emergency Repatriation Eligibility Application Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0474	ICR Reference No: 202204-0970-004
Status: Received in OIRA	Previous ICR Reference No: 201903-0970-002
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: U.S. Repatriation Program Forms
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 04/12/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2022
Responses	2,535	51,524
Time Burden (Hours)	802	9,204
Cost Burden (Dollars)	0	0

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Abstract: This information collection allows OHSEPR to fulfill its statutory responsibilities to provide temporary assistance to repatriates. OHSEPR uses this information collection to conduct both emergency and routine repatriation. These forms allow OHSEPR to conduct Program operations regarding: 1) determining a repatriate’s eligibility for temporary assistance 2) granting extensions for temporary assistance beyond the 90-day eligibility period 3) collecting repatriation loans from repatriates and to grant loan waivers and deferrals 4) reimbursing states and service providers for temporary assistance provided to eligible repatriates and 5) pre-approving states’ costs for emergency repatriation. OHSEPR made changes to all eight forms to ensure the information collected aligns with Program statutes and regulations as well as the purpose and use of the form. Revisions include clarifying statutory authority and general instructions on completing and submitting the forms. These changes make the forms more user friendly. OHSEPR also reduced the burden estimates to make them more accurate.

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

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:
	87 FR 6569	02/04/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 21662	04/12/2022
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Emergency Repatriation Eligibility Application	1	Emergency Repatriation Eligibility Application
Emergency Repatriation Reimbursement Request	1	Emergency Repatriation Reimbursement Request
Emergency Repatriation Request for Cost Approval and Federal Support	1	Emergency Repatriation Request for Cost Approval and Federal Support
Loan Waiver and Deferral Application	1	Loan Waiver and Deferral Application
Refusal of Temporary Assistance	1	Refusal of Temporary Assistance
Repatriation Repayment and Privacy Agreement	1	Repatriation Repayment and Privacy Agreement
Routine Repatriation Reimbursement Request	1	Routine Repatriation Reimbursement Request
Temporary Assistance Extension Request	1	Temporary Assistance Extension Request

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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	2,535	51,524	0	-48,989	0	0
Annual Time Burden (Hours)	802	9,204	0	-8,402	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: OHSEPR made changes to all eight forms and adjusted the burden and cost estimates to make them more accurate, based on current numbers and experiences to-date. See section A12 of the Supporting Statement for information about updates to burden estimates. In addition to updates to burden estimates as described in the Supporting Statement, the forms were uploaded in order for this submission and as such, some of the changes to burden on IC lines with ROCIS are due to shifting the order of entries.

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Annual Cost to Federal Government: $188,568

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? No

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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: 04/12/2022

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