Information Collection

Request for Certification of Foreign National Adult Victims of Human Trafficking

IC 215217 under ICR 202201-0970-008 · OMB 0970-0454.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0454 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Request for Certification of Foreign National Adult Victims of Human Trafficking Form
Attachment B_Shepherd RFC Webform Instructions.pdf Instruction
Attachment B_Shepherd RFC Webform Instructions.pdf Instruction
1 Request for HHS Certification of Foreign National Adult RFC SSA_1.21.22.docx Form
1 Request for HHS Certification of Foreign National Adult Attachment A_Proposed RFC_3.31.22_Clean.pdf Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Request for Certification of Foreign National Adult Victims of Human Trafficking	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	1	Request for HHS Certification of Foreign National Adult Victims of Human Trafficking	Attachment A_Proposed RFC_3.31.22_Clean.pdf		Yes	Yes	Fillable Printable
Instruction			Attachment B_Shepherd RFC Webform Instructions.pdf		Yes	Yes	Printable Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,300	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	433	-367	800
Annual IC Time Burden (Hours)	433	33	400
Annual IC Cost Burden (Dollars)	0	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.