Information Collection

Client Characteristics and Program Entry

IC 239400 under ICR 202210-0970-006 · 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⚠️ Notice: This information collection may be referencing outdated material.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 Program Entry	Form
OMB 0970-0542_Revised DVHT Reporting Reference Guide_10.17.22.docx	Instruction
OMB 0970-0542_Revised DVHT Reporting Reference Guide_Clean_2.16.23.docx	Instruction
1 Client Characteristics and Enrollment Form OMB 0970-0542_Revised DVHT Performance Indicators_10.17.22.docx	Form
1 Client Characteristics and Program Entry Form OMB 0970-0542_Revised DVHT Performance Indicators_Clean_2.16.23.docx	Form

IC Title:

Client Characteristics and Program Entry

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 Program Entry Form	OMB 0970-0542_Revised DVHT Performance Indicators_Clean_2.16.23.docx		Yes	Yes	Fillable Fileable
Instruction			OMB 0970-0542_Revised DVHT Reporting Reference Guide_Clean_2.16.23.docx		Yes	Yes	Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,700

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	567	-69	636
Annual IC Time Burden (Hours)	425	-211	636
Annual IC Cost Burden (Dollars)	0	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.