Information Collection

IDCM Intake Assessment

IC 216998 under ICR 201709-0970-005 · 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⚠️ Notice: This information collection may be referencing outdated material.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 IDCM Intake Assessment	Form and Instruction
1 Access to Behavioral Health Assessment Access to Behavioral Health Assessment.pdf	Form and Instruction
1 Child and Youth Services Assissement Child and Youth Services Assessment.pdf	Form and Instruction
1 Client Intake Demographic Information Client Intake Demographic Informaton.pdf	Form and Instruction
1 Clothing Assessment Clothing Assessment.pdf	Form and Instruction
1 Family Financial Evaluation Family Financial Evaluation.pdf	Form and Instruction
1 Food Assessment Food Assessment.pdf	Form and Instruction
1 Furniture and Appliances Assessment Furniture and Appliances Assessment.pdf	Form and Instruction
1 Health Insurance and Access to Health Care Health Insurance and Access to Health Care.pdf	Form and Instruction
1 Housing Assessment Housing Assessment.pdf	Form and Instruction
1 Lanaguage Assessment Language Assessment.pdf	Form and Instruction
1 Legal Referral Services Legal Referral Services.pdf	Form and Instruction
1 Post-Disaster Financial Assessment Post-Disaster Financial Assessment.pdf	Form and Instruction
1 Pre-Disaster Financial Assessment Pre-Disaster Financial Assessment.pdf	Form and Instruction
1 Senior Services Assessment Senior Services Assessment.pdf	Form and Instruction
1 Transportation Assessment Transportation Assessment.pdf	Form and Instruction
Client Consent To The Release of Confidential Information.docx Client Consent	IC Document

Information Collection (IC) Details

View Information Collection (IC)

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	Available Electronically?	Electronic Capability
Form and Instruction	1	Client Intake Demographic Information	Client Intake Demographic Informaton.pdf	No	Printable Only
Form and Instruction	1	Clothing Assessment	Clothing Assessment.pdf	No	Printable Only
Form and Instruction	1	Family Financial Evaluation	Family Financial Evaluation.pdf	No	Printable Only
Form and Instruction	1	Food Assessment	Food Assessment.pdf	No	Printable Only
Form and Instruction	1	Furniture and Appliances Assessment	Furniture and Appliances Assessment.pdf	No	Printable Only
Form and Instruction	1	Health Insurance and Access to Health Care	Health Insurance and Access to Health Care.pdf	No	Printable Only
Form and Instruction	1	Housing Assessment	Housing Assessment.pdf	No	Printable Only
Form and Instruction	1	Lanaguage Assessment	Language Assessment.pdf	No	Printable Only
Form and Instruction	1	Legal Referral Services	Legal Referral Services.pdf	No	Printable Only
Form and Instruction	1	Post-Disaster Financial Assessment	Post-Disaster Financial Assessment.pdf	No	Printable Only
Form and Instruction	1	Pre-Disaster Financial Assessment	Pre-Disaster Financial Assessment.pdf	No	Printable Only
Form and Instruction	1	Senior Services Assessment	Senior Services Assessment.pdf	No	Printable Only
Form and Instruction	1	Transportation Assessment	Transportation Assessment.pdf	No	Printable Only
Form and Instruction	1	Access to Behavioral Health Assessment	Access to Behavioral Health Assessment.pdf	No	Printable Only
Form and Instruction	1	Child and Youth Services Assissement	Child and Youth Services Assessment.pdf	No	Printable Only

Federal Enterprise Architecture Business Reference Module

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: 0 %

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	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.