Information Collection

Resident Intake Form

IC 213343 under ICR 201701-2528-002 · OMB 2528-0304.

Documents and Forms

Document Name Document Type
Resident Intake Form Form
Resident Intake Form Appendix C_Resident Intake Form.docx Form

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Resident Intake Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	N/A	Resident Intake Form	Appendix C_Resident Intake Form.docx		Yes	No	Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 400	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	-400	400
Annual IC Time Burden (Hours)	-67	67
Annual IC Cost Burden (Dollars)	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.