# Submission for Office of Management and Budget Review; Medical Assessment Form and Dental Assessment Form (Office of Management and Budget 0970-0466)
**AGENCY:**
Office of Refugee Resettlement, Administration for Children and Families, U.S. Department of Health and Human Services.
**ACTION:**
Request for public comments.
**SUMMARY:**
The Administration for Children and Families (ACF) is requesting a 3-year extension of the forms Medical Assessment Form (formerly, the Initial Medical Exam (IME) Form and Supplemental Tuberculosis (TB) Screening Form) and Dental Assessment Form (formerly, the Dental Exam Form) (Office of Management and Budget (OMB) #0970-0466, expiration December 31, 2023). Changes are proposed to the currently approved forms.
**DATES:**
*Comments due within 30 days of publication.* OMB must make a decision about 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 within 30 days of publication of this notice to *www.reginfo.gov/public/do/PRAMain.* Find this particular information collection by selecting “Currently under 30-day Review-Open for Public Comments” or by using the search function. You can also obtain copies of the proposed collection of information by emailing *[email protected].* Identify all emailed requests by the title of the information collection.
**SUPPLEMENTARY INFORMATION:**
The ACF ORR places unaccompanied children in their custody in care provider programs until unification with a qualified sponsor. Care provider programs are required to provide children with a range of services including medical, dental, and mental health care. Each child must receive an initial medical exam (IME) within 2 business days of admission to an ORR care provider program or temporary influx care facility. The IME satisfies *Flores* requirements which require a “complete medical examination, including a screening for infectious disease”. The purposes of the IME are to assess general health, administer vaccinations in keeping with U.S. standards (also required by *Flores* ), identify health conditions that require further attention, and detect contagious diseases of public health importance, such as influenza or TB. The IME is performed by a licensed health care provider and comprised of a complete medical history and physical exam, risk, and age-based laboratory screenings, TB screenings and immunizations. In addition, children may be referred to a specialist by their healthcare provider for acute or chronic conditions that require additional evaluation. If a child is in ORR custody 60 to 90 days after admission, they must receive an initial dental exam, or sooner if directed by state licensing requirements. Children who are in ORR care for an extended length of time may require urgent or routine medical and dental well-child evaluations.
The forms are used as worksheets for generalist healthcare providers and pediatric and other medical specialty healthcare providers to compile information that would otherwise have been collected during the health evaluation. Once completed, the forms are given to care provider program staff for entry into ORR's secure, electronic data record system. Data is used to monitor the health of unaccompanied children while in ORR care, for case management of any identified illnesses/conditions and to ensure care provider program compliance with ORR requirements.
ORR has merged the former IME Form and Supplemental TB Screening Form into one form, the Medical Assessment Form which will be used during all medical evaluations with a mid-level or higher medical professional. ORR has incorporated other changes to the forms to streamline the flow of data collection, clarify the intent of certain fields, improve data quality, and ensure alignment with ORR requirements. In addition, ORR has written instructional letters for the Medical Assessment Form and Dental Assessment Form to explain the purpose of the forms and provide general guidance on completion to healthcare providers.
*Respondents:* Healthcare providers (pediatricians, medical specialists, and dentists), Care Provider Program Staff.
**Annual Burden Estimates**
| Instrument | Respondent | Annual | Total number of responses per | Average | Annual burden hours |
| --- | --- | --- | --- | --- | --- |
| Medical Assessment Form | Pediatricians, General | 300 | 840 | 0.22 | 55,440 |
| Dental Assessment Form | Dentists | 250 | 64 | 0.12 | 1,920 |
*Estimated Total Annual Burden Hours:* 60,990.
| Instrument | Respondent | Annual | Total number of responses per | Average | Annual burden hours |
| --- | --- | --- | --- | --- | --- |
| Medical Assessment Form completed by a medical professional | Care Provider Program Staff | 500 | 537 | 0.33 | 88,605 |
| Dental Assessment Form | | 500 | 32 | 0.17 | 2,720 |
*Estimated Total Annual Burden Hours:* 99,825.
*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])
Mary B. Jones,
ACF/OPRE Certifying Officer.