Information Collection

Client Characteristics and Enrollment Form

IC 239400 under ICR 202001-0970-006 · OMB 0970-0542.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0542 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Client Characteristics and Enrollment Form	Form
1 Client Characteristics and Enrollment Form 1 - OTIP-0564 - DVHT New - Client Characteristics and Enrollment Form CLEAN.pdf	Form
DVHT Grantee Reporting Reference Guide_1.21.20.docx DVHT Grantee Reporting Reference Guide	IC Document

IC Title:

Client Characteristics and Enrollment 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	1	Client Characteristics and Enrollment Form	1 - OTIP-0564 - DVHT New - Client Characteristics and Enrollment Form CLEAN.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: 1,908

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	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	636	636
Annual IC Time Burden (Hours)	636	636
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
DVHT Grantee Reporting Reference Guide	DVHT Grantee Reporting Reference Guide_1.21.20.docx	01/23/2020

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