2015-26467. Submission for OMB Review; Comment Request

Title: U.S. Repatriation Program Forms.

OMB No.: 0970-NEW (two of the forms have prior OMB No: [SSA-3955 & SSA-2061]).

Description: The United States (U.S.) Repatriation Program was established by Title XI, Section 1113 of the Social Security Act (Assistance for U.S. Citizens Returned from Foreign Countries) to provide temporary assistance to U.S. citizens and their dependents who have been identified by the Department of State (DOS) as having returned, or been brought from a foreign country to the U.S. because of destitution, illness, war, threat of war, or a similar crisis, and are without available resources immediately accessible to meet their needs. The Secretary of the Department of Health and Human Services (HHS) was provided with the authority to administer this Program. On or about 1994, this authority was delegated by the HHS Secretary to the Administration for Children and Families (ACF) and later re-delegated by ACF to the Office of Refugee Resettlement. The Repatriation Program works with States, Federal agencies, and non-governmental organizations to provide eligible individuals with temporary assistance for up to 90-days. This assistance is in the form of a loan and must be repaid to the Federal Government.

The Program was later expanded in response to legislation enacted by Congress to address the particular needs of persons with mental illness (24 U.S.C. Sections 321 through 329). Further refinements occurred in response to Executive Order (EO) 11490 (as amended) where HHS was given the responsibility to “develop plans and procedures for assistance at ports of entry to U.S. personnel evacuated from overseas areas, their onward movement to final destination, and follow-up assistance after arrival at final destination.” In addition, under EO 12656 (53 CFR 47491), “Assignment of emergency preparedness responsibilities,” HHS was given the lead responsibility to develop plans and procedures in order to provide assistance to U.S. citizens and others evacuated from overseas areas.

In order to effectively and efficiently manage these legislative authorities, the Program has been divided into two major activities, Emergencies and Non-Emergencies Repatriation Activities. Operationally, these two Program activities involve different kinds of preparation, resources, and implementation. However, the core Program statute, regulations, policies and administrative procedures for these two Programs are essentially the same. The ongoing routine arrivals of individual repatriates and the repatriation of individuals with mental illness constitute the Program Non-emergency activities. Emergency Activities are characterized by contingency events such as civil unrest, war, threat of war or similar crisis, among other incidents. Depending on the type of event, number of evacuees and resources available, ACF will provide assistance utilizing two scalable mechanisms, emergency repatriations or group repatriations. Emergency repatriations assume the evacuation of 500 or more individuals, while group repatriations assume the evacuation of 50-500 individuals.

The Program provides services through agreements with the States, U.S. Territories, Federal agencies, and Non-governmental agencies. The list of Repatriation Forms is as follows:

1. The HHS Repatriation Program: Emergency and Group Processing Form: under 45 CFR 211 and 212, HHS is to make findings setting forth the pertinent facts and conclusions according to established standards to determine whether an individual is an eligible person. This form allows authorized staff to gather necessary information to determine eligibility and needed services. This form is to be utilized during emergency repatriation activities. Individuals interested in receiving Repatriation assistance will complete appropriate portions of this form. State personnel assisting with initial intake activities will use this form as a guide to perform a preliminary eligibility assessment. An authorized federal staff from the ACF will make final eligibility determinations.

2. The HHS Repatriation Program: Privacy and Repayment Agreement Form: under 45 CFR 211 and 212, individuals who receive Program assistance are required to repay the federal government for the cost associated to the services received. This form authorizes HHS to release personal identifiable information to partners for the purpose of providing services to eligible repatriates. In addition, through this form, eligible repatriates agree to accept services under the terms and conditions of the Program. Specifically, eligible repatriates commit to repay the federal government for all temporary services received through the Program. This form is to be completed by eligible repatriates or authorized legal custodians. Exemption applies to unaccompanied minors and individuals eligible under 45 CFR 211, if no legal custodian is identified.

3. The HHS Repatriation Program: Refusal of Temporary Assistance Form: for individuals who are eligible to receive repatriation assistance but opt to relinquish services, this form is utilized to confirm and record repatriate's decision to refuse receiving Program assistance. This form is to be completed by eligible repatriates or authorized legal custodian. Exemption applies to unaccompanied minors and individuals eligible under 45 CFR 211, if no legal custodian is identified.

4. The HHS Repatriation Program: Emergency and Group Repatriation Financial Form: under Section 1113 of the Social Security Act, HHS is authorized to provide temporary assistance directly or through utilization of the services and facilities of appropriate public or private agencies and organizations, in accordance with agreements providing for payment, as may be determined by HHS. This form is to be utilized and completed by agencies that have entered into an agreement with ORR to request reimbursement of reasonable and allowable costs, both administrative and actual temporary services.

5. The HHS Repatriation Program: Non-emergency Monthly Financial Statement Form: under Section 1113 of the Social Security Act, HHS is authorized to provide temporary assistance directly or through arrangements, in accordance with agreements providing for payment, as may be determined by HHS. This form is to be utilized and completed by the States and other authorized ORR agencies to request reimbursement of reasonable and allowable costs, both administrative and actual temporary services, associated to the direct provision of temporary assistance to eligible repatriates.

6. The HHS Repatriation Program: Repatriation Loan Waiver and Deferral Request Form: in accordance with 45 CFR 211 & 212 individuals who have received Repatriation assistance may be eligible to receive a waiver or deferral of their repatriation loan. This form is to be completed by eligible repatriates, authorized legal custodian, or authorized agency/individual. Exemption applies to unaccompanied minors and individuals eligible under 45 CFR 211, if no legal custodian is identified.

7. The HHS Repatriation Program: Temporary Assistance Extension Request Form: under 45 CFR 211 & 212 temporary assistance may be furnished beyond the 90 days eligibility period if the repatriate meets the qualifications established under Program regulations. This form is to be completed by the eligible repatriate, authorized legal custodian, or the authorized agency/individual. This form should be submitted to ORR or its designated grantee generally 14 days prior to the expiration of the 90 days eligibility period.

8. The HHS Repatriation Program: State Request for Federal Support Form: During emergency repatriation activities, States activated by ORR are to use this form to request support and/or assistance from HHS, including but not limited to required pre-approval of expenditures, augmentation of State personnel, funding, reimbursement, among other things.

Respondents: Designated state, federal, and/or non-governmental agencies/individuals and eligible repatriates. Responders are authorized by 42 U.S.C. 1313 and 24 U.S.C. 321-329; Executive Order 12656 (as amended by E.O. 13074, February 9, 1998; E.O. 13228, October 8, 2001; E.O. 13286, February 28, 2003); and regulations found under 45 CFR 211 & 212.

Annual Burden Estimates

Instrument	Number of respondents	Number of responses per respondent	Average burden hours per response	Total burden hours
The HHS Repatriation Program: Emergency and Group Processing Form	25,000 or more depending on the Emergency	1	0.30	7,500 or more.
The HHS Repatriation Program: Privacy and Repayment Agreement Form	1,000 will increase during emergencies	1	0.05	50 or more.
The HHS Repatriation Program: Refusal of Temporary Assistance Form	15 or more	1	0.05	0.75 or more.
The HHS Repatriation Program: Emergency and Group Repatriation Financial Form	15 or more	1	0.30	4.5 or more.
The HHS Repatriation Program: Non-emergency Monthly Financial Statement Form	52 or more	12	0.30	187 or more.
The HHS Repatriation Program: Repatriation Loan Waiver and Referral Request Form	800 or more	1	0.30	240 or more.
The HHS Repatriation Program: State Request for Federal Support	20 or more	1	0.30	6 or more.
The HHS Repatriation Program: Temporary Assistance Extension Request Form	50 or more	1 or more	0.30	15 or more.

Estimated Total Annual Burden Hours: 8,003.

Additional Information: Copies of the proposed collection may be obtained by writing to the Administration for Children and Families, Office of Planning, Research and Evaluation, 370 L'Enfant Promenade SW., Washington, DC 20447, Attn: ACF Reports Clearance Officer. All requests should be identified by the title of the information collection. Email address: [e-mail].

OMB Comment: 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. 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: [e-mail], Attn: Desk Officer for the Administration for Children and Families.

Robert Sargis,

Reports Clearance Officer.