Resource Referral Form – Case Manager

Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0619 can be found here:

Documents and Forms

Document Name Document Type
Form 3 Resource Referral Form – Case Manager Form and Instruction
3 Resource Referral Form 3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx Form and Instruction
3 Resource Referral Form 3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Resource Referral Form – Case Manager	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

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	Resource Referral Form	3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: OHESPR Repatriation and Disaster Human Services Case Management Records	FR Citation: 88 FR 63109

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Change Due to Adjustment in Agency Estimate
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	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.