2015-19001. Submission for OMB Review; Comment Request

Title: Initial Medical Exam Form and Initial Dental Exam Form.

OMB No.: 0970-NEW.

Description: The Administration for Children and Families' Office of Refugee Resettlement (ORR) places unaccompanied minors in their custody in licensed care provider facilities until reunification with a qualified sponsor. Care provider facilities are required to provide children with services such as classroom education, mental health services, and health care. Pursuant to 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), care provider facilities, on behalf of ORR, shall arrange for appropriate routine medical and dental care, family planning services, and emergency health care services, including a complete medical examination (including screening for infectious disease) within 48 hours of admission, excluding weekends and holidays, unless the minor was recently examined at another facility; appropriate immunizations in accordance with the U.S. Public Health Service (PHS), Center for Disease Control; administration of prescribed medication and special diets; appropriate mental health interventions when necessary for each minor in their care.

The forms are to be used as worksheets for clinicians, medical staff, and the health department to compile information that would otherwise have been collected during the initial medical or dental exam. Once completed, the forms will be given to shelter staff for data entry into ORR's electronic data repository known as the `UAC Portal'. Data will be used to record UC health on admission and for case management of any identified illnesses/conditions.

Respondents: Clinicians, Health Department staff, Office of Refugee Resettlement Grantee staff.

Annual Burden Estimates

Instrument	Number of respondents	Number of responses per respondent	Average burden hours per response	Total burden hours
Estimated Respondent Burden for Responding
Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form)	150	270	0.17	6,885
Initial Dental Exam Form	150	27	0.08	324

Estimated Total Burden Hours: 7,209.

Annual Burden Estimates

Instrument	Number of respondents	Number of responses per respondent	Average burden hours per response	Total burden hours
Estimated Respondent Burden for Recordkeeping
Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form)	150	270	0.08	3,240
Initial Dental Exam Form	150	27	0.08	324

Estimated Total Annual Burden 3,564.

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.