Information Collection

Client Service Use and Delivery

IC 239401 under ICR 202509-0970-011 · OMB 0970-0542.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Client Service Use and Delivery	Form
Form 4 FY25 DVHT Performance Indicators Client Service Use and Delivery	Form
Form 4b Reporting Workbook - For use if unable to report in ATIMS Client Service Use and Delivery	Form and Instruction
FY25 DVHT Reporting Reference Guide - clean_v2.docx	Instruction
FY25 DVHT Reporting Reference Guide - clean_v2.docx	Instruction
4 FY25 DVHT Performance Indicators FY25 DVHT Performance Indicators - clean _v2.docx	Form
4 FY25 DVHT Performance Indicators FY25 DVHT Performance Indicators - clean _v2.docx	Form
4b Reporting Workbook - For use if unable to report in ATIM FY25 DVHT Reporting Workbook_For Use Only If Recipient Unable to Report in ATIMS_v2.xlsx	Form and Instruction
4b Reporting Workbook - For use if unable to report in ATIM FY25 DVHT Reporting Workbook_For Use Only If Recipient Unable to Report in ATIMS_v2.xlsx	Form and Instruction

IC Title:

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.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	4	Yes	Yes	Fillable Fileable
Instruction		Yes	Yes	Printable Only
Form and Instruction	4b	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: 900

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	300	-267	567
Annual IC Time Burden (Hours)	75	-67	142
Annual IC Cost Burden (Dollars)	0	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.

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