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Proposed Information Collection Activity; Comment Request

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Proposed Projects

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

OMB No.: New.


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), licensed programs, on behalf of the Administration for Children and Families' Office of Refugee Resettlement (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 its 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 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.Start Printed Page 21246

Annual Burden Estimates

InstrumentNumber of respondentsNumber of responses per respondentAverage burden hours per responseTotal burden hours
Initial Medical Exam Form (including Appendix A: Supplemental TB Screening Form)206155.257982.5
Initial Dental Exam Form11628.08259.8

Estimated Total Annual Burden Hours: 8242.3.

In compliance with the requirements of Section 506(c)(2)(A) of the Paperwork Reduction Act of 1995, the Administration for Children and Families is soliciting public comment on the specific aspects of the information collection described above. Copies of the proposed collection of information can be obtained and comments may be forwarded 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. Email address: All requests should be identified by the title of the information collection.

The Department specifically requests comments on: (a) Whether the proposed collection of information is necessary for the proper performance of the functions of the agency, including whether the information shall have practical utility; (b) the accuracy of the agency's estimate of the burden of the proposed collection of information; (c) the quality, utility, and clarity of the information to be collected; and (d) ways to minimize the burden of the collection of information on respondents, including through the use of automated collection techniques or other forms of information technology. Consideration will be given to comments and suggestions submitted within 60 days of this publication.

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Robert Sargis,

Reports Clearance Officer.

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[FR Doc. 2015-08835 Filed 4-16-15; 8:45 am]