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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 4 Case Record Notes	Form and Instruction	Unchanged	Available
Form 4 Case Record Notes – Case Manager	Form and Instruction	Unchanged	Repair queued
Form 3 Resource Referral Form	Form and Instruction	Unchanged	Available
Form 3 Resource Referral Form – Case Manager	Form and Instruction	Unchanged	Repair queued
Form 2 Case Management Plan	Form and Instruction	Unchanged	Available
Form 2 Case Management Plan – Case Manager	Form and Instruction	Unchanged	Repair queued
Form 1 Disaster Human Services Case Management Intake Assessment Form	Form and Instruction	Modified	Available
Form 1 Disaster Human Services Case Management Intake Assessment – Survivor	Form and Instruction	Modified	Repair queued
NonSub Change Request - Compliance DHSCM - 10Feb2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-02-10	Available
NonSub Change Request - Compliance DHSCM - 10Feb2025.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-02-10	Repair queued
SSA - OHSEPR IDCM Intake Assessment_Extension 2024_0970-0619_fnl.docx	Supporting Statement A	Uploaded 2024-01-30	Available
SSA - OHSEPR IDCM Intake Assessment_Extension 2024_0970-0619_fnl.docx	Supporting Statement A	Uploaded 2024-01-30	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
262635	Survivor Satisfaction Survey – Survivor	Other-Survey	Unchanged
262634	Case Record Notes – Case Manager	Form and Instruction	Unchanged	Case Record Notes
262634	Case Record Notes – Case Manager	Form and Instruction	Unchanged
262632	Resource Referral Form – Case Manager	Form and Instruction	Unchanged	Resource Referral Form
262632	Resource Referral Form – Case Manager	Form and Instruction	Unchanged
262631	Case Management Plan – Case Manager	Form and Instruction	Unchanged	Case Management Plan
262631	Case Management Plan – Case Manager	Form and Instruction	Unchanged
262629	Disaster Human Services Case Management Intake Assessment – Survivor	Form and Instruction	Modified	Disaster Human Services Case Management Intake Assessment Form
262629	Disaster Human Services Case Management Intake Assessment – Survivor	Form and Instruction	Modified

ICR Details

OMB Control No: 0970-0619	ICR Reference No: 202502-0970-023
Status: Active	Previous ICR Reference No: 202401-0970-017
Agency/Subagency: HHS/ACF	Agency Tracking No: OHSEPR
Title: Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/21/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/15/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2027	03/31/2027	03/31/2027
Responses	45,000	0	45,000
Time Burden (Hours)	42,750	0	42,750
Cost Burden (Dollars)	0	0	0

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Abstract: The Administration for Children and Families (ACF) is requesting an extension with no changes to this information collection, which was originally approved in October 2023 through an emergency review, as authorized under 44 U.S.C. 3507 (subsection j). The forms under this request enable ACF’s Office of Human Services Emergency Preparedness and Response (OHSEPR) to provide case management support during disasters. The Disaster Human Services Case Management (DHSCM) program is authorized through appropriations language under the Children and Families Services account. It is operated by the Administration for Children and Families' (ACF) Office of Human Services Emergency Preparedness and Response (OHSEPR). OHSEPR is the lead in the Department for Health and Human Services (HHS) for human service preparation for, response to, and recovery from, natural disasters. The materials included in this request are necessary for OHSEPR to provide responsive disaster human services case management operations to support families that are currently displaced. The Administration for Children and Families (ACF) has updated the Disaster Human Services Intake Assessment Form to comply with Executive Order 14168, Defending Women from Gender Ideology Extremism and Restoring Biological Truth to the Federal Government (Defending Women). The remaining four forms are already in compliance and do not require changes.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 69191	10/04/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 5909	01/30/2024
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Case Management Plan – Case Manager	2	Case Management Plan
Case Record Notes – Case Manager	4	Case Record Notes
Disaster Human Services Case Management Intake Assessment – Survivor	1	Disaster Human Services Case Management Intake Assessment Form
Resource Referral Form – Case Manager	3	Resource Referral Form
Survivor Satisfaction Survey – Survivor

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	45,000	45,000	0	0	0	0
Annual Time Burden (Hours)	42,750	42,750	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,890,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 02/15/2025

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