Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan

Forms and Documents

Document Name	Status
Form 4 Case Record Notes – Case Manager Form and Instruction	New
Form 3 Resource Referral Form – Case Manager Form and Instruction	New
Form 2 Case Management Plan – Case Manager Form and Instruction	New
Form 1 Disaster Human Services Case Management Intake Assessment – Survivor Form and Instruction	New
SSA - OHSEPR IDCM Intake Assessment_EmergencyRequest_9.29.23.docx Supporting Statement A	2023-10-03

IC Document Collections

IC ID	Document Title	Status
262635	Survivor Satisfaction Survey – Survivor Other-Survey	New
262634	Case Record Notes – Case Manager Form and Instruction	New
262632	Resource Referral Form – Case Manager Form and Instruction	New
262631	Case Management Plan – Case Manager Form and Instruction	New
262629	Disaster Human Services Case Management Intake Assessment – Survivor Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202310-0970-002
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/ACF	Agency Tracking No:
Title: Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 10/06/2023
Date Submitted to OIRA: 10/03/2023

	Requested	Previously Approved
Expiration Date	6 Months From Approved
Responses	45,000	0
Time Burden (Hours)	42,750	0
Cost Burden (Dollars)	0	0

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Abstract: The Disaster Human Services Case Management (DHSCM) program is authorized through appropriations language under the Children and Families Services account. It is operated by OHSEPR, which is the lead in HHS for human service preparation for, response to, and recovery from, natural disasters. The wildfires that began August 8, 2023, have displaced thousands of residents. The state and county do not have existing internal capability to conduct disaster case management operations to support residents. OHSEPR’s previous OMB-approved collection for disaster case management operations was limited to FEMA’s Immediate Disaster Case Management program and the collection expired July 31, 2023. Absent approval of the new collection, OHSEPR and ACF would not be able to provide disaster human services case management services to disaster survivors in Hawai’i and other impacted jurisdictions.

Emergency Justfication: The Administration for Children and Families (ACF) is requesting emergency review and approval of this information collection by OMB, as authorized under 44 U.S.C. 3507 (subsection j). The proposed forms are necessary to enable ACF’s Office of Human Services Emergency Preparedness and Response (OHSEPR) to provide case management support to residents of the state of Hawai’i that were impacted by wildfires beginning August 8, 2023. The wildfires have destroyed more than 3,000 homes and impacted nearly 9,000 residents in Maui County. The information collection is essential to the mission of the agency and is necessary to support vulnerable families. Emergency review and approval is necessary to prevent public harm that is reasonably likely to result if normal clearance procedures are followed as it would result in the initiation of disaster human services case management operations to support families that are currently displaced.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

IC Title	Form No.	Form Name
Case Management Plan – Case Manager	2	Case Management Plan
Case Record Notes – Case Manager	4	Case Record Notes
Disaster Human Services Case Management Intake Assessment – Survivor	1	Disaster Human Services Case Management Intake Assessment Form
Resource Referral Form – Case Manager	3	Resource Referral Form
Survivor Satisfaction Survey – Survivor

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ICR Summary of Burden

	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	0	0	27,000	18,000	0
Annual Time Burden (Hours)	42,750	0	0	24,750	18,000	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $1,890,000

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     Yes

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     Yes

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/03/2023

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