Attachment B - Medical Assessment Form Instructional Letter for Medical Providers

Dear Colleague,

Under your care is an unaccompanied child who is in the custody of the Office of Refugee Resettlement (ORR) in the Department of Health and Human Services (DHHS). As such, ORR must collect specific information on healthcare services received by the child. While in ORR custody, children are placed in government-funded care provider programs that are responsible for providing day-to-day care. The ultimate goals of ORR are to ensure the health and safety of the child while in custody and to unify the child with their sponsor, as soon as possible.

The Medical Assessment Form (MAF) must be completed by the evaluating healthcare provider during every visit with a generalist or specialist MD, DO, NP or PA, including urgent care and health department visits, and returned to the care provider program staff member at the conclusion of the evaluation. The MAF must also be completed during a child’s initial medical exam (IME). The IME is a comprehensive health assessment designed to identify acute and chronic medical conditions, and screen children for diseases of public health concern within 2 business days of admission into ORR care.

The MAF is comprised of 6 sections - General Information, History and Assessment, Review of Systems and Physical Exam, Laboratory Testing, TB Screening and Diagnosis and Plan. All sections must be completed by the evaluating healthcare provider at the IME; however, the TB Lab Testing and Lab Testing sections may be skipped if they are not relevant during other evaluations (see details below). As a reminder of the IME requirements, an * has been placed after the section headers on the form.

Please note the following section-specific guidance:

• Review of Systems and Physical Exam section - Physical exam: If a physical exam was performed, but not all systems were evaluated, please provide a reason in the space provided (Note, all systems must be evaluated at the IME with findings documented on the form, however the genitourinary exam should be deferred if there are no clinical concerns).

• Lab Testing section: ORR requires specific age- and risk-based testing at the IME as noted in the “Indicators” column of the lab testing table (e.g., hepatitis B surface antigen testing for children who report sexual abuse/assault or injection drug use, or were born in or lived in countries¹ with intermediate (2% to 7%) or high (> 8%) prevalence of chronic hepatitis B virus (HBV) infection; syphilis testing for children under 2 years of age if the biological mother is not with the child in ORR care or children over 2 years of age who report consensual sexual activity or sexual abuse or assault). If this testing is performed outside of the IME, please enter the info for the appropriate tests, otherwise, this section can be skipped.

• TB Screening section: Must be completed for the IME and anytime there is a new concern for active tuberculosis (signs/symptoms) or the child is a suspect case (bacteriologic specimens are being collected), otherwise, this section can be skipped.

• Diagnosis and Plan section –

• Medications: If a medication is given/prescribed, a corresponding diagnosis must be indicated.

• ­Special healthcare needs/follow-up services - Onsite care provider clinician evaluation: Indicate if you feel the child would benefit from receiving additional care with program-based licensed mental health therapists or therapists who are working toward licensure (Note, all children routinely meet with program-based therapists on a weekly basis).

• Clearance to travel: As stated, ORR’s primary objective is the safe and timely unification of children with their sponsors. For children identified with potential acute health conditions, ORR relies on healthcare provider recommendations to determine whether indicated follow-up services must occur prior to a child’s travel to unify with their sponsor or if they may be addressed after unification. Given this, please clearly identify on the form if a child is cleared to travel with or without restrictions by the conclusion of their evaluation with you.

Please ensure that copies of all health records, including office notes, immunization records, lab results and imaging reports are forwarded to care provider program staff as soon as they are available. Also, please verify that all information entered on the form is legible and complete as this information will be transcribed and uploaded into a secure electronic data system owned by ORR.

If you have any questions or concerns regarding the information collected on this form or require additional direction, please contact the ORR’s Division of Health for Unaccompanied Children (DHUC) at DCSMedical@acf.hhs.gov.

Thank you,

Director, Division of Health for Unaccompanied Children (DHUC)

Unaccompanied Children Programs

Office of Refugee Resettlement

Administration for Children and Families

U.S. Department of Health and Human Services

1 https://wwwnc.cdc.gov/travel/yellowbook/2020/travel-related-infectious-diseases/hepatitis-b#5182