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⚠️ Notice: This information collection may be outdated.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 Name	Status
Form 4 Case Record Notes – Case Manager Form and Instruction	Unchanged
Form 3 Resource Referral Form – Case Manager Form and Instruction	Unchanged
Form 2 Case Management Plan – Case Manager Form and Instruction	Unchanged
Form 1 Disaster Human Services Case Management Intake Assessment – Survivor Form and Instruction	Unchanged
SSA - OHSEPR IDCM Intake Assessment_Extension 2024_0970-0619_fnl.docx Supporting Statement A	2024-01-30

IC Document Collections

IC ID	Document Title	Status
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