Serious Medical Procedure Request (SMR) Form
OMB Information Collection Request
0970 - 0561
Supporting Statement Part A - Justification
November 2023
Type of Request: Revision
Submitted By:
Office of Refugee Resettlement
Administration for Children and Families
U.S. Department of Health and Human Services
Summary
The Administration for Children and Families (ACF) is requesting a revision to the Serious Medical Procedure Request (SMR) Form (OMB #0970-0561, expiration 02/29/2024) and a three-year extension of approval. Proposed changes to the currently approved forms are described in section A15.
Circumstances Making the Collection of Information Necessary
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 appropriate medical, mental health and dental services per the Flores Settlement Agreement, Exhibit 1(A)(2) (Attachment A). Children identified as having complex medical/dental conditions may require a procedure while in ORR custody to maintain and promote their health and wellbeing.
Procedures requiring general anesthesia, surgeries, and invasive diagnostic procedures (e.g., cardiac catheterization, invasive biopsy, amniocentesis) require advance ORR approval. Before ORR can approve, the following data must be collected and submitted to ORR by the care provider program and the lead surgeon - diagnoses, procedure name(s), current procedural terminology (CPT) code(s), clinical indications, potential risks/complications of procedure, timing for procedure/proposed date, potential adverse outcomes if the procedure is not performed, timeframe for recovery, potential follow-up procedures, follow-up care, and points of contact. In certain circumstances, ORR will waive the completion of the SMR form if it is deemed to be in the best interest of the child’s safety and well-being (e.g., during a hospitalization or emergency department visit, medical emergencies).
Purpose and Use of the Information Collection
The purpose of this form is to allow ORR to collect standardized information on the risks and benefits of a recommended serious medical or dental procedure and use this information to make an informed decision on the necessity of the recommended procedure while the child is in ORR care.
The form is used as a worksheet for care provider program staff and surgeons to compile information that would otherwise have been collected during the health evaluation. Once completed, care provider program staff upload the form and supporting documentation into ORR’s secure, electronic data record system, the UC Portal, and send an email notification to ORR that the SMR packet is ready for review.
Only ORR staff and care provider program staff assigned to the child will have access to this information. Access to this information will terminate for care provider program staff 45 days after transfer or discharge. This information will not be shared with other agencies.
Use of Improved Information Technology and Burden Reduction
Currently, care provider program staff upload the SMR form and related health documentation to the child’s electronic record in the UC Portal. The uploaded form is accessible to ORR and, in the event of a transfer, the new care provider program to ensure continuity of care.
Efforts to Identify Duplication and Use of Similar Information
The information being collected by these instruments are not obtainable from other sources.
Impact on Small Businesses or Other Small Entities
The proposed information collection request does not impact small businesses or other small entities. This information collection primarily affects the operations of the federal government, particularly, ORR’s management of the care and custody of unaccompanied children.
Consequences of Collecting the Information Less Frequently
Collecting this information less frequently would impede ORR from performing its charged duty of administering required and appropriate healthcare services for children in its custody.
Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
This request fully complies with the regulation 5 CFR 1320.5.
Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency
In accordance with the Paperwork Reduction Act of 1995 (Pub. L. 104-13) and Office of Management and Budget (OMB) regulations at 5 CFR Part 1320 (60 FR 44978, August 29, 1995), ACF published a notice in the Federal Register announcing the agency’s intention to request an OMB review of this information collection activity. This notice was published on September 13, 2023, Volume 88, Number 176, pages 62798-62799, and provided a sixty-day period for public comment. We did not receive comments.
Explanation of Any Payment or Gift to Respondents
No monetary incentives or gifts are provided to respondents.
Assurance of Confidentiality Provided to Respondents
ORR established a system of records to ensure the level of confidentiality pursuant to the Privacy Act. 5 U.S.C. 552a. ORR’s system of records notice was titled “09-80-0321 ORR Division of Children's Services Records” and published on July 18, 2016, at 81 FR 46682.
The data collected from this information collection is not shared with external agencies.
Justification for Sensitive Questions
The SMR Form collects sensitive information in the form of diagnoses, procedure names, and clinical indications as ORR cannot decide on the necessity of a recommended procedure in the absence of this info. ORR does not ask for information of a sensitive nature beyond what is needed to provide services and make healthcare decisions. Recorded information becomes part of the child’s health record and is viewable only to care provider program staff who are directly responsible for the child, ORR field-based program managers, and ORR federal staff. Children are provided with copies of their health records at the time of discharge from ORR custody with the expectation that collected information will be shared with their new healthcare providers.
Estimates of Annualized Burden Hours and Costs
The calculation of annual burden estimates is based on the following factors:
ORR currently funds approximately 250 care provider programs and 2 influx care facilities (ICFs) and expects to continue the trend of increasing capacity each year.
Estimates on the total number of responses per respondent annually were derived from annual counts over the last three fiscal years.
During the last 2 fiscal years, an annual average of 115 SMR forms were submitted across all 250 programs and ICFs. For each form, a care provider program staff member completes page 1, and a surgeon completes pages 2 and 3.
Recordkeeping burden in the form of uploading documentation of all health-related services rendered into ORR’s secure electronic record system will be incurred only by care provider program staff; healthcare providers will not incur recordkeeping burden for this collection.
The cost to surgeon respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Pediatric Surgeons [29-1243] and wage data from May 2022, which is $174.51 per hour. To account for fringe benefits and overhead, the rate was multiplied by two which is $349.02. The estimate of annualized cost to respondents for hour burden is $349.02 times 20 hours or $6,980. https://www.bls.gov/oes/current/oes291243.htm
The cost to care provider program staff respondents was calculated using the Bureau of Labor Statistics (BLS) job code for Child, Family, and School Social Workers in the industry of Other Residential Care Facilities [21-1021] and wage data from May 2022, which is $27.25 per hour. To account for fringe benefits and overhead, the rate was multiplied by two which is $54.50. The estimate of annualized cost to respondents for hour burden is $54.50 times 8 hours or $436 and for recordkeeping burden, $54.50 times 9 hours or $491. https://www.bls.gov/oes/current/oes211021.htm
The estimated total annual cost for respondents (healthcare providers and care provider program staff) to collect the information is $7,907.
Estimated Reporting Time
Information Collection Title |
Respondent |
Total Number of Respondents |
Total Number of Responses Per Respondent |
Average Burden Hours Per Response |
Total Burden Hours |
Annual Burden Hours |
Average Hourly Wage |
Total Annual Cost |
Serious Medical Procedure Request (SMR) Form |
Pediatric surgeons |
250 |
1.38 |
.17 |
59 |
20 |
$349.02 |
$6,980 |
Care provider program staff |
250 |
1.38 |
.07 |
24 |
8 |
$54.50 |
$436 |
|
Estimated Annual Burden Total: |
83 |
28 |
Estimated Annual Cost Total: |
$7,416 |
||||
Estimated Recordkeeping Time
Information Collection Title |
Respondent |
Annual Number of Respondents |
Total Number of Responses Per Respondent |
Average Burden Hours Per Response |
Total Burden Hours |
Annual Burden Hours |
Average Hourly Wage |
Total Annual Cost |
Serious Medical Procedure Request (SMR) Form |
Care provider program staff |
250 |
1.38 |
.08 |
28 |
9 |
$54.50 |
Estimates of Other Total Annual Cost Burden to Respondents and Record Keepers
There are no other costs to respondents and record keepers.
Annualized Cost to the Federal Government
The forms were developed by a GS-13, step 6-level public health analyst in the Boston area who spent approximately 50 hours revising the forms. To account for fringe benefits and overhead, the hourly rate for this position ($62.62) was multiplied by two for a total of $125.24. Therefore, the cost to create the paper version of the form was $6,262.
Upon submission to ORR, the form will be reviewed for completeness by an ORR Quality Assurance Specialist (GS-11) The hourly rate for this position, including fringe benefits and overhead is $84.07. It is estimated that the Quality Assurance Specialist will spend approximately 850 hours a year processing request packets. Therefore, the annual cost to process the SMR request packet is approximately $71,460.
The complete request packet will then be forwarded to an ORR Medical Officer (GS-14) to determine if the procedure/surgery in ORR care is warranted. To account for fringe benefits and overhead, the hourly rate for this position ($71.88) was multiplied by two for a total of $143.76. It is estimated that the ORR Medical Officer will spend approximately 81 hours a year reviewing request packets. Therefore, the annual cost to review the SMR request packet is approximately $11,645.
If the procedure is deemed necessary by the ORR Medical Officer, the SMR packet will be submitted to ORR leadership personnel (GS-15) for final approval. To account for fringe benefits and overhead, the hourly rate for this position ($84.55) was multiplied by two for a total of $169.10. It is estimated that the ORR leadership staff member will spend approximately 20 hours a year reviewing request packets. Therefore, the annual cost to approve the SMR request packet is approximately $3,382.
It is estimated that the annual cost to the government for this information collection will be $92,749 over the next 3 years.
Explanation for Program Changes or Adjustments
Several changes were made to the SMR Form including, 1) rewriting the intro section and adding guidance on completing and submitting the form, 2) adding fields on consent, procedure name and planned follow-up procedures, 3) rewording existing fields, and 4) removing unnecessary fields. ORR has incorporated these changes to the form to streamline the flow of data collection, clarify intent and purpose of the form and fields, improve data quality, and ensure alignment with ORR program policies. The overall estimated time per form has increased by 1 minute and has been adjusted to reflect a decrease by 1 minute for care provider program staff and an increase by 2 minutes for surgeons.
Plans for Tabulation and Publication and Project Time Schedule
ORR does not plan to publish the results of these information collections.
Reason(s) Display of OMB Expiration Date is Inappropriate
ORR intends to display the expiration date for OMB approval of the information collections on the instruments.
Exceptions to Certification for Paperwork Reduction Act Submissions
No exceptions are necessary for this information collection.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Jones, Molly (ACF) |
| File Modified | 0000-00-00 |
| File Created | 2023-11-19 |