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

Forms and Documents

Document Name	Status
Form 1 Public Health Investigation Form: Active TB Form	Unchanged
Form 1 Public Health Investigation Form: Non-TB Illness Form	Unchanged
Form 1 Health Assessment Form Form	Modified
Health Assessment Form_0509_Updated 05092022.docx Justification for No Material/Nonsubstantive Change	2022-05-09
SUPSTAT_HHS OMB 0970-0509_Final.docx Supporting Statement A	2020-09-28
Attachment A - Flores Agreement.doc Supplementary Document	2018-01-30

IC Document Collections

IC ID	Document Title	Status
229906	Public Health Investigation Form: Active TB Form	Unchanged
229904	Public Health Investigation Form: Non-TB Illness Form	Unchanged
229902	Health Assessment Form Form	Modified

ICR Details

OMB Control No: 0970-0509	ICR Reference No: 202205-0970-004
Status: Received in OIRA	Previous ICR Reference No: 202009-0970-013
Agency/Subagency: HHS/ACF	Agency Tracking No: ORR
Title: Health Assessment Form, Public Health Investigation Form: Non-TB Illness, and Public Health Investigation Form: Active TB
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: 05/09/2022

	Requested	Previously Approved
Expiration Date	12/31/2023	12/31/2023
Responses	108,225	108,225
Time Burden (Hours)	38,454	38,454
Cost Burden (Dollars)	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 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. To capture behavioral and mental health concerns and symptoms during these evaluations, disorder-based mental health diagnosis options were listed in the Behavioral and Mental Health Concerns category within the Diagnosis section of the current Health Assessment Form. However, since the date of approval, an ORR Behavioral and Mental Health Team comprised of licensed mental health professionals was created and after careful consideration, the Team believes the current format may cause a child to be prematurely and inappropriately labeled with a mental health disorder if the child is first evaluated by a non-mental health provider. Per ORR guidelines, a child identified with a symptom-based diagnosis during an evaluation with a healthcare provider would be referred to a specialist for evaluation and a disorder-based diagnosis. Therefore, ORR feels that it is in the best interest of the child to provide symptom-based mental health diagnoses as well as disorder-based diagnoses on the Health Assessment Form.

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Authorizing Statute(s): US Code: 6 USC 279 Name of Law: Flores Settlement 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:
	85 FR 15476	03/18/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	85 FR 60802	09/28/2020
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Health Assessment Form	1	Health Assessment Form
Public Health Investigation Form: Active TB	1	Public Health Investigation Form: Active TB
Public Health Investigation Form: Non-TB Illness	1	Public Health Investigation Form: Non-TB Illness

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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	108,225	108,225	0	0	0	0
Annual Time Burden (Hours)	38,454	38,454	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: In the previously approved information collection, the annual burden estimate did not include the time required by healthcare providers to complete the Health Assessment form, as it was assumed this information was already collected by the provider and did not impose additional burden. In order to account for the time needed for healthcare providers to fill out the ORR-developed Health Assessment form, however, ORR has since increased the burden estimate for this request.

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Annual Cost to Federal Government: $18,027

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: 05/09/2022

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