Information Collection

Barriers to Service Delivery and Monitoring Form

IC 237962 under ICR 201910-0970-001 · OMB 0970-0467.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0467 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Barriers to Service Delivery and Monitoring Form	Form
4 Barriers to Service Delivery and Monitoring Form Attachment F - OTIP-0499 - TVAP Revision - Barriers to Service Delivery and Monitoring Form_10.01.19.pdf	Form

IC Title:

Barriers to Service Delivery and Monitoring Form

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

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	4	Barriers to Service Delivery and Monitoring Form	Attachment F - OTIP-0499 - TVAP Revision - Barriers to Service Delivery and Monitoring Form_10.01.19.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 261

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

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	1,305	1,305
Annual IC Time Burden (Hours)	218	218
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.