OMB control number

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

OMB 0970-0619 · HHS/ACF.

OMB 0970-0619

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.

The latest form for Office of Human Services Emergency Preparedness and Response Disaster Human Services Case Management Intake Assessment, Resource Referral, and Case Management Plan expires 2027-03-31 and can be found here.

Latest Forms, Documents, and Supporting Material

Document Name
Form 4 Case Record Notes – Case Manager Form and Instruction
Form 3 Resource Referral Form – Case Manager Form and Instruction
Form 2 Case Management Plan – Case Manager Form and Instruction
Form 1 Disaster Human Services Case Management Intake Assessment – Survivor Form and Instruction
NonSub Change Request - Compliance DHSCM - 10Feb2025.docx Justification for No Material/Nonsubstantive Change
SSA - OHSEPR IDCM Intake Assessment_Extension 2024_0970-0619_fnl.docx Supporting Statement A
Survivor Satisfaction Survey – Survivor Other-Survey
Case Record Notes – Case Manager Form and Instruction
Resource Referral Form – Case Manager Form and Instruction
Case Management Plan – Case Manager Form and Instruction
Disaster Human Services Case Management Intake Assessment – Survivor Form and Instruction

All Historical Document Collections

202502-0970-023	No material or nonsubstantive change to a currently approved collection	2025-02-15
202401-0970-017 Approved without change	Extension without change of a currently approved collection	2024-01-30
202310-0970-002 Approved without change	New collection (Request for a new OMB Control Number)	2023-10-03

OMB Details

Disaster Human Services Case Management Intake Assessment – Survivor

Federal Enterprise Architecture: Community and Social Services - Social Services

Form 1

Disaster Human Services Case Management Intake Assessment Form

Fillable Fileable

Form and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.