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Federal forms, ICRs, and supporting documents

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 202502-0970-023 · OMB 0970-0619 · Received in OIRA

Forms and Documents
DocumentTypeStatusAvailability
Form 4 Case Record Notes – Case Manager Form and Instruction Unchanged Missing upstream
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 Modified Repair queued
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 Missing upstream
IC Document Collections
IC IDCollectionTypeStatusForm
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 Modified
ICR Details
0970-0619 202502-0970-023
Received in OIRA 202401-0970-017
HHS/ACF OHSEPR
Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan
No material or nonsubstantive change to a currently approved collection   No
Regular 02/15/2025
  Requested Previously Approved
03/31/2027 03/31/2027
45,000 45,000
42,750 42,750
0 0
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.
None
None
Not associated with rulemaking
  88 FR 69191 10/04/2023
89 FR 5909 01/30/2024
No
  Total Request 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
No
No
$1,890,000
No
    Yes
    Yes
No
No
No
No
Molly Buck 202 205-4724 [email protected]
  No
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:
 
 
 
 
 
 
 
    (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;
 
 
 
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.
02/15/2025