View Information Collection (IC)
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Agenda
Reg Review
ICR
View Information Collection (IC)
View Information Collection (IC)
IC Title:
IDCM Intake Assessment
Agency IC Tracking Number:
OHSEPR
Is this a Common Form?
No
IC Status:
Removed
Obligation to Respond:
Required to Obtain or Retain Benefits
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form and Instruction
1
Access to Behavioral Health Assessment
Access to Behavioral Health Assessment.pdf
No
Printable Only
Form and Instruction
1
Child and Youth Services Assissement
Child and Youth Services Assessment.pdf
No
Printable Only
Form and Instruction
1
Client Intake Demographic Information
Client Intake Demographic Informaton.pdf
No
Printable Only
Form and Instruction
1
Clothing Assessment
Clothing Assessment.pdf
No
Printable Only
Form and Instruction
1
Family Financial Evaluation
Family Financial Evaluation.pdf
No
Printable Only
Form and Instruction
1
Food Assessment
Food Assessment.pdf
No
Printable Only
Form and Instruction
1
Furniture and Appliances Assessment
Furniture and Appliances Assessment.pdf
No
Printable Only
Form and Instruction
1
Health Insurance and Access to Health Care
Health Insurance and Access to Health Care.pdf
No
Printable Only
Form and Instruction
1
Housing Assessment
Housing Assessment.pdf
No
Printable Only
Form and Instruction
1
Lanaguage Assessment
Language Assessment.pdf
No
Printable Only
Form and Instruction
1
Legal Referral Services
Legal Referral Services.pdf
No
Printable Only
Form and Instruction
1
Post-Disaster Financial Assessment
Post-Disaster Financial Assessment.pdf
No
Printable Only
Form and Instruction
1
Pre-Disaster Financial Assessment
Pre-Disaster Financial Assessment.pdf
No
Printable Only
Form and Instruction
1
Senior Services Assessment
Senior Services Assessment.pdf
No
Printable Only
Form and Instruction
1
Transportation Assessment
Transportation Assessment.pdf
No
Printable Only
Federal Enterprise Architecture Business Reference Module
Line of Business:
Community and Social Services
Subfunction:
Social Services
Privacy Act System of Records
Title:
FR Citation:
Number of Respondents:
3,500
Number of Respondents for Small Entity:
0
Affected Public:
Individuals or Households
Percentage of Respondents Reporting Electronically:
0 %
Approved
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
0
0
-3,500
0
0
3,500
Annual IC Time Burden (Hours)
0
0
-2,333
0
0
2,333
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Client Consent
Client Consent To The Release of Confidential Information.docx
09/02/2015
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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