Information Collection

Barriers to Service Delivery and Monitoring

IC 239404 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Form 3 Barriers to Service Delivery and Monitoring 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
3 Barriers to Service Delivery and Monitoring Form OMB 0970-0542_Revised DVHT Performance Indicators_10.17.22.docx Form
3 Barriers to Service Delivery and Monitoring Form OMB 0970-0542_Revised DVHT Performance Indicators_Clean_2.16.23.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Barriers to Service Delivery and Monitoring	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	3	Barriers to Service Delivery and Monitoring 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: 35	Number of Respondents for Small Entity: 5

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	47	-133	180
Annual IC Time Burden (Hours)	8	-22	30
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.