IDCM Intake Assessment

Immediate Disaster Case Management Intake Assessment

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0461 can be found here:

Documents and Forms

Document Name Document Type
Form 1 IDCM Intake Assessment Form and Instruction
1 OHSEPR IDCM Intake Assessment ACF OHSEPR IDCM Intake Assessment.pdf Form and Instruction
Client Consent To The Release of Confidential Information.docx Client Consent IC Document

Information Collection (IC) Details

IC Title:	IDCM Intake Assessment	Agency IC Tracking Number:	OHSEPR

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	OHSEPR IDCM Intake Assessment	ACF OHSEPR IDCM Intake Assessment.pdf		Yes	Yes	Fillable Printable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 3,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 50 %

	Approved	Previously Approved
Annual Number of Responses for this IC	3,500	3,500
Annual IC Time Burden (Hours)	2,333	2,333
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Client Consent	Client Consent To The Release of Confidential Information.docx	09/02/2015

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