The Regional Center Intake Form

Counseling Information Form; Regional Center Intake Form and Quarterly (formerly Monthlly) Report of Operations Form.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2105-0554 can be found here:

Documents and Forms

Document Name Document Type
Form DOT F 4500 The Regional Center Intake Form Form and Instruction
DOT F 4500 The Regional Center Intake Form DOT_F_4500_SBTRC_Field_Office_Intake_Form.doc Form and Instruction

Information Collection (IC) Details

IC Title:	The Regional Center Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation: 49 CFR parts 23 and 26 (To search for a specific CFR, visit the Code of Federal Regulations.)

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	DOT F 4500	The Regional Center Intake Form	DOT_F_4500_SBTRC_Field_Office_Intake_Form.doc		Yes	Yes	Fillable Fileable

Line of Business: Transportation

Subfunction: Ground Transportation

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	Number of Respondents for Small Entity: 100

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.