Information Collection

Client Characteristics and Enrollment Form

IC 239400 under ICR 202108-0970-011 · 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⚠️ Notice: This information collection may be referencing outdated material.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 0970-0542 - DVHT Client Characteristics and Enrollment Form_Updated.pdf	Form
1 Client Characteristics and Enrollment Form 0970-0542 - DVHT Client Characteristics and Enrollment Form_Clean.pdf	Form
DVHT Grantee Reporting Reference Guide_1.21.20.docx DVHT Grantee Reporting Reference Guide	IC Document
FY21 DVHT Grantee Reporting Reference Guide_Clean.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: 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	1	Client Characteristics and Enrollment Form	0970-0542 - DVHT 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	Previously Approved
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	FY21 DVHT Grantee Reporting Reference Guide_Clean.docx	09/21/2021

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