OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Medical Assessment Form and Dental Assessment Form

ICR 202312-0970-002 · OMB 0970-0466 · Active

Forms and Documents
Document
Name
Status
Form
 Unchanged
Form
 Unchanged
Form
 Modified
Form
 Modified
Form
 Modified
Form
 Modified
Form
 Modified
Form
 Modified
Form
 Unchanged
Form
 Unchanged
Form
 Modified
Form
 Modified
Justification for No Material/Nonsubstantive Change
2023-12-05
Justification for No Material/Nonsubstantive Change
2023-12-05
Supplementary Document
2023-08-02
Supplementary Document
2023-08-02
Supplementary Document
2023-08-02
Supplementary Document
2023-08-02
Supporting Statement A
2023-08-02
Supporting Statement A
2023-08-02
Supplementary Document
2023-08-02
Supplementary Document
2023-08-02
IC Document Collections
IC ID
Document
Title
Status
261420 Unchanged
261420 Unchanged
261419 Modified
261419 Modified
261416 Modified
261416 Modified
261414 Modified
261414 Modified
217789 Unchanged
217789 Unchanged
217788 Modified
217788 Modified
ICR Details
0970-0466 202312-0970-002
Active 202308-0970-002
HHS/ACF ORR
Medical Assessment Form and Dental Assessment Form
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 12/08/2023
Retrieve Notice of Action (NOA) 12/06/2023
  Inventory as of this Action Requested Previously Approved
10/31/2026 10/31/2026 10/31/2026
619,000 0 619,000
160,815 0 160,815
0 0 0
The Medical Assessment Form was approved by OMB on October 26, 2023, as part of the Medical Assessment Form and Dental Assessment Form information collection. The purpose of the Medical Assessment Form is to collect standardized health information on unaccompanied children during evaluations with generalist medical providers, pediatricians, and other medical specialty providers. In November 2023, ORR hired a Reproductive Health specialist who reviewed the Medical Assessment Form and recommended changes to the reproductive health history section and genito-urinary/reproductive diagnosis fields. ORR believes these changes will aid healthcare providers in performing a thorough assessment and creating an informed healthcare plan. ORR would like to: • replace the field “if unknown, months since LMP" with 2 options, “Approximate” and “Exact” in the last menstrual period (LMP) field, • rename the “Current contraceptive use” field to “Contraceptive use” and add a specify field with examples, • replace the field “Pregnancy: Gravida ___ Parity ___; location & age of child(ren):” with “Pregnancy history” and add discrete options to capture the number of each pregnancy outcome (e.g., vaginal deliveries, ectopic pregnancies), • add a new free text field called “Pregnancy/postpartum complications”, and • update several diagnoses under the Genito-urinary/Reproductive category in the Diagnosis and Plan section
US Code: 6 USC 279 Name of Law: Flores Agreement
  
None
Not associated with rulemaking
  88 FR 35883 06/01/2023
88 FR 52166 08/07/2023
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 619,000 619,000 0 0 0 0
Annual Time Burden (Hours) 160,815 160,815 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$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.
12/06/2023