OMB.report

Federal forms, ICRs, and supporting documents

Information Collection Request

Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness

ICR 202312-0970-003 · OMB 0970-0509 · Active

Forms and Documents
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Justification for No Material/Nonsubstantive Change
2023-09-18
Justification for No Material/Nonsubstantive Change
2023-09-18
Supporting Statement A
2023-09-18
Supporting Statement A
2023-09-18
Supplementary Document
2023-08-03
Supplementary Document
2023-08-03
Supplementary Document
2023-08-03
Supplementary Document
2023-08-03
IC Document Collections
IC ID
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Title
Status
261448 Unchanged
261448 Unchanged
261447 Unchanged
261447 Unchanged
261446 Modified
261446 Modified
229906 Unchanged
229906 Unchanged
229904 Unchanged
229904 Unchanged
229902 Modified
229902 Modified
ICR Details
0970-0509 202312-0970-003
Active 202309-0970-005
HHS/ACF ORR
Mental Health Assessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness
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
09/30/2026 09/30/2026 09/30/2026
207,800 0 207,800
17,406 0 17,406
0 0 0
The Mental Health Assessment Form was approved by OMB on September 16, 2023, as part of the Mental Health Asessment Form, Public Health Investigation Form: Active TB, and Public Health Investigation Form: Non-TB Illness Form information collection. The purpose of the Mental Health Assessment is to collect standardized health information on unaccompanied children during evaluations with mental health providers. In November 2023, ORR hired a Reproductive Health specialist who reviewed the Mental Health Assessment Form and recommended changes to the reproductive health history section. ORR believes these changes will aid mental health 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,
US Code: 6 USC 279 Name of Law: Flores Settlement Agreement
  
None
Not associated with rulemaking
  88 FR 35879 06/01/2023
88 FR 52172 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 207,800 207,800 0 0 0 0
Annual Time Burden (Hours) 17,406 17,406 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