Information Collection

Resource Referral Form – Case Manager

IC 262632 under ICR 202401-0970-017 · OMB 0970-0619.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

IC Title:

Resource Referral Form â Case Manager

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Unchanged

Obligation to Respond: Voluntary

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 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 %

table that charts list of burden
	Approved	Previously Approved
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

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.