Information Collection

Barriers to Service Delivery and Monitoring

IC 239404 under ICR 202502-0970-031 · 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⚠️ Notice: This information collection may be referencing outdated material.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 4 Barriers to Service Delivery and Monitoring Form Barriers to Service Delivery and Monitoring	Form
FY25 DVHT Reporting Reference Guide_CleanWithChanges.docx	Instruction
FY25 DVHT Reporting Reference Guide_CleanWithChanges.docx	Instruction
4 Barriers to Service Delivery and Monitoring Form FY25 DVHT Performance Indicators_CleanWithChanges.docx	Form
4 Barriers to Service Delivery and Monitoring Form FY25 DVHT Performance Indicators_CleanWithChanges.docx	Form
FY25 DVHT PPR Workbook_SpecifyQuarterNo._SpecifyGrantRecipientName_CleanWithChanges.xlsx FY25 DVHT PPR Workbook	IC Document
FY25 DVHT PPR Workbook_SpecifyQuarterNo._SpecifyGrantRecipientName_CleanWithChanges.xlsx FY25 DVHT PPR Workbook	IC Document

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Instruction					Yes	Yes	Printable Only
Form	4				Yes	Yes	Fillable Fileable

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 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	47	47
Annual IC Time Burden (Hours)	8	8
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FY25 DVHT PPR Workbook		02/25/2025

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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