Information Collection

Resident Intake Form

IC 213343 under ICR 201410-2528-001 · OMB 2528-0304.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 2528-0304 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Resident Intake Form	Form
Resident Intake Form Appendix C_Resident Intake Form.docx	Form

IC Title:

Resident Intake Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Resident Intake Form	Appendix C_Resident Intake Form.docx		Yes	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 400

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	400	400
Annual IC Time Burden (Hours)	67	67
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.