Form HUD-New Beneficiary Referral Request form

OMB Control Number: 2535-0122

Expiration Date: XX-XX-XXXX

The information collection requirements contained in this document have been approved by the Office of Management and Budget (OMB) under the Paperwork Reduction Act of 1995 (44 U.S.C. 3501-3520) and assigned OMB control number 2535-0122. There is no personal information contained in this application. Information on activities and expenditures of grant funds is public information and is generally available for disclosure. Recipients are responsible for ensuring confidentiality when disclosure is not required. In accordance with the Paperwork Reduction Act, HUD may not conduct or sponsor, and a person is not required to respond to, a collection of information unless the collection displays a currently valid OMB control number.

"Public reporting burden for this collection of information is estimated to average 0.03 hours for beneficiaries or prospective beneficiaries and no more than 2 hours for service providers. For beneficiaries or prospective beneficiaries, this includes the time for reviewing and responding to the form. For service providers, this includes collecting the form, reviewing the request, making the referral, follow-up (if required) and recordkeeping.  This collection of information is authorized under Executive Order 13559 (75 FR 71319).  The information is used to register beneficiary objections to the religious character of a service provider and to allow the service provider to undertake reasonable efforts to refer a beneficiary to an alternative provider. Response to this request for information is voluntary for beneficiaries or prospective beneficiaries and mandatory for service providers in cases where a beneficiary or prospective beneficiary requests a referral.  This service provider may not collect this information, and you are not required to complete this form unless it displays a currently valid OMB control number.  No confidentiality is assured.” 

Privacy Act Statement: The information collected on this form is considered sensitive and is protected by the Privacy Act. The Privacy Act requires that these records be maintained with appropriate administrative, technical, and physical safeguards to ensure their security and confidentiality. In addition, these records should be protected against any anticipated threats or hazards to their security or integrity which could result in substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom the information is maintained.

BENEFICIARY REFERRAL REQUEST

If you object to receiving services from us based on the religious character of our organization, please complete this form and return it to the program contact identified above. Your use of this form is voluntary.

If you object to the religious character of our organization, we must make reasonable efforts to identify and refer you to an alternative provider to which you have no such objection. We cannot guarantee, however, that in every instance, an alternative provider will be available. With your consent, we will follow up with you or the organization to which you are referred to determine whether you have contacted that organization.

( ) Please check if you want to be referred to another provider.

Please provide the following information if you want us to follow up with you:

Your Name:

Best way to reach you (phone/address/email):

Please provide the following information if you want us to follow up with the provider only.

Your Name:

You are permitted to withhold your name, though if you choose to do so, we will be unable to follow up with you or the provider about your referral.

( ) Please check if you do not want follow-up.

FOR STAFF USE ONLY

Date of Objection:

Referral (check one):

( ) Individual was referred to (name of alternative provider and contact information):

( ) Individual left without a referral

( ) No alternative provider is available—summarize below what efforts you made to identify an alternative (including reaching out to HUD or the intermediary, if applicable):

1. Follow-up date:

( ) Individual contacted alternative provider

( ) Individual did not contact alternative provider

2. Staff name and initials:

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