Health Assessment Form,
Public Health Investigation Form: Non-TB Illness, and Public Health
Investigation Form: Active TB
Revision of a currently approved collection
No
Regular
08/08/2023
Requested
Previously Approved
36 Months From Approved
12/31/2023
207,800
108,225
17,406
38,454
0
0
The Administration for Children and
Families (ACF) is requesting a three-year extension of approval for
the forms Mental Health Assessment Form (formerly, the Health
Assessment Form), Public Health Investigation Form: Active TB and
Public Health Investigation Form: Non-TB Illness (OMB #0970-0509,
expiration 12/31/2023). Revisions are proposed to the currently
approved forms as described in section A15. The ACF Office of
Refugee Resettlement (ORR) places unaccompanied children in their
custody in care provider programs until unification with a
qualified sponsor. Care provider programs are required to ensure
children receive the appropriate medical, mental health and dental
services per the Flores Settlement Agreement, Exhibit 1(A)(2)
(Attachment A). While in care, children meet with onsite mental
health counselors on a regular basis. If a child is identified as
potentially having a more serious mental health condition, they are
referred to a psychiatrist, psychiatric nurse practitioner or
physician’s assistant, licensed psychologist, or other licensed
mental health provider (e.g., social worker). Children may be
exposed to nationally reportable infectious diseases during the
journey to the U.S., while in the custody of the Customs and Border
Protection after crossing the border, or during their stay in ORR
custody. Public health interventions such as quarantine,
vaccination or lab testing may be initiated to reduce possible
disease transmission. Following an exposure, children are assessed
onsite by care provider program staff and if found to be
symptomatic, referred to a healthcare provider for evaluation. ORR
requires care providers to maintain records on each child to ensure
that health-related evaluations, diagnoses, lab results, and
treatments are documented and included in the child’s discharge
packet at the time of reunification. ORR requires the Mental Health
Assessment and Public Health Investigation Forms information
collections to implement and maintain compliance with the Flores
Settlement Agreement.
US Code:
6 USC
279 Name of Law: Flores Settlement Agreement
The former Health Assessment
Form used for medical and mental health evaluations has been
updated to only capture mental health information collected during
evaluations with a psychiatrist, psychiatric nurse practitioner or
physician’s assistant, licensed psychologist, any other community
based licensed mental health provider (e.g., social worker) and
onsite clinicians at residential treatment centers in the ORR
network, and renamed to the Mental Health Assessment Form. This
change will simplify and streamline the data collection process for
healthcare providers as the fields are tailored towards mental
health evaluations. In addition, several changes/updates were made
including 1) adding fields to the General Information section to
capture information on translation services and purpose of visit,
2) enhancing the History and Physical Assessment section to obtain
a more thorough health and social history, 3) reformatting and
building out several fields to clarify intent of current high-level
specify fields, and 4) adding/revising the physical and mental
status exams and diagnoses. These changes were made to ensure the
healthcare providers are performing complete physical and mental
health exams and documenting diagnoses in a standardized manner. On
both Public Health Investigation forms, updates were made to the
wording of several fields to clarify intent and unnecessary fields
were removed to reduce burden. Lastly, an instructional letter was
written for mental health professionals completing the Mental
Health Assessment Form that explains the purpose and data
collection guidelines (Attachment B). Adjustments have been made to
burden estimates where applicable and burden estimates have been
broken out to display burden more clearly for each type of
respondent and activity.
$789,687
No
Yes
Yes
No
No
No
Yes
Molly Buck 202 205-4724
mary.buck@acf.hhs.gov
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:
(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;
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.
Form 1 Public Health Investigation Form: Non-TB Illness - Recordkeeping Time
Supporting Statement A_Mental Health Assessment Form and Public Health Investigation Forms_fnl.docx
Public Health Investigation Form: Non-TB Illness - Recordkeeping Time