# Submission for OMB Review; Information Collection Activity; Initial Medical Exam Form and Dental Exam Form
**AGENCY:**
Office of Refugee Resettlement, Administration for Children and Families, HHS.
**ACTION:**
Request for public comment.
**SUMMARY:**
The Office of Refugee Resettlement (ORR), Administration for Children and Families (ACF), U.S. Department of Health and Human Services (HHS), is requesting to continue the data collection approved by the Office of Management and Budget (OMB) under expedited review.
**DATES:**
*Comments due within 30 days of publication.* OMB is required to make a decision concerning the collection of information between 30 and 60 days after publication of this document in the *Federal Register* . Therefore, a comment is best assured of having its full effect if OMB receives it within 30 days of publication.
**ADDRESSES:**
Written comments and recommendations for the proposed information collection should be sent directly to the following: Office of Management and Budget, Paperwork Reduction Project, Email: *[email protected]* , Attn: Desk Officer for the Administration for Children and Families.
Copies of the proposed collection may be obtained by emailing *[email protected].* Alternatively, copies can also be obtained by writing to the Administration for Children and Families, Office of Planning, Research, and Evaluation, 330 C Street SW, Washington, DC 20201, Attn: ACF Reports Clearance Officer. All requests, emailed or written, should be identified by the title of the information collection.
**SUPPLEMENTARY INFORMATION:**
*Description:* ACF was granted a 180-day approval by OMB to collect information about instances of COVID-19. A request for review under normal procedures will now be submitted to continue collection of this information as part of the information collection under OMB #0970-0466.
*Respondents:* Healthcare providers (Pediatricians and Dentists) and ORR Grantee Staff.
*Annual Burden Estimates:*
**Estimated Opportunity Costs for Respondents**
**Pediatricians, General**
| Information collection title | Annual | Annual | Average | Total | Annual |
| --- | --- | --- | --- | --- | --- |
| Initial Medical Exam Form (excluding Appendix A: Supplemental TB Screening Form) | 195 | 271 | 0.22 | 34,878 | 11,626 |
*Estimated Annual Burden Total:* 11,626.
**ORR Grantee Staff**
| Information collection title | Annual | Annual | Average | Total | Annual |
| --- | --- | --- | --- | --- | --- |
| Appendix A: Supplemental TB Screening Form | 195 | 271 | 0.05 | 7,926 | 2,642 |
*Estimated Annual Burden Total:* 2,642.
**Dentists**
| Information collection title | Annual | Annual | Average | Total | Annual |
| --- | --- | --- | --- | --- | --- |
| Dental Exam Form | 195 | 46 | 0.08 | 2,154 | 718 |
*Estimated Annual Burden Total:* 718.
**Estimated Recordkeeping Costs**
**ORR Grantee Staff**
| Information collection title | Annual | Annual | Average | Total | Annual |
| --- | --- | --- | --- | --- | --- |
| Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form) | 195 | 271 | 0.33 | 52,317 | 17,439 |
| Dental Exam Form | 195 | 46 | 0.17 | 4,575 | 1,525 |
*Estimated Annual Burden Total:* 18,964.
**Authority:**
6 U.S.C. 279: 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]).
John M. Sweet, Jr.,
ACF/OPRE Certifying Officer.