Information Collection Request
Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan
ICR 202401-0970-017 · OMB 0970-0619 · Received in OIRA
⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0970-0619 can be found here:
Forms and Documents
| Document | Type | Status | Availability |
|---|---|---|---|
 Form 4 Case Record Notes – Case Manager |
Form and Instruction | Unchanged | Repair queued |
| Form 3 Resource Referral Form – Case Manager |
Form and Instruction | Unchanged | Repair queued |
| Form 2 Case Management Plan – Case Manager |
Form and Instruction | Unchanged | Repair queued |
| Form 1 Disaster Human Services Case Management Intake Assessment – Survivor |
Form and Instruction | Unchanged | Repair queued |
 SSA - OHSEPR IDCM Intake Assessment_Extension 2024_0970-0619_fnl.docx |
Supporting Statement A | Uploaded 2024-01-30 | Repair queued |
IC Document Collections
| IC ID | Collection | Type | Status | Form |
|---|---|---|---|---|
| 262635 |  Survivor Satisfaction Survey – Survivor |
Other-Survey | Unchanged | |
| 262634 | Case Record Notes – Case Manager |
Form and Instruction | Unchanged | |
| 262632 | Resource Referral Form – Case Manager |
Form and Instruction | Unchanged | |
| 262631 | Case Management Plan – Case Manager |
Form and Instruction | Unchanged | |
| 262629 | Disaster Human Services Case Management Intake Assessment – Survivor |
Form and Instruction | Unchanged |
ICR Details
| Status | Received in OIRA |
|---|---|
| Agency/Subagency | HHS/ACF |
| OMB Control No | 0970-0619 |
| Type of Information Collection | Extension without change of a currently approved collection |
| Previous ICR Reference No | 202310-0970-002 |
| Date Submitted to OIRA | 1969-12-31 |
| Requested Expiration Date | 1969-12-31 |