Information Collection

IDCM Intake Assessment

IC 216998 under ICR 201509-0970-003 · OMB 0970-0461.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 OHSEPR IDCM Intake Assessment 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

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1				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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
Client Consent		09/02/2015

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

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