View Information Collection (IC)

View Information Collection (IC)

IC Title:	Client Characteristics and Enrollment Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	1	Client Characteristics and Enrollment Form	0970-0542 - DVHT Client Characteristics and Enrollment Form_Clean.pdf		Yes	Yes	Fillable Fileable

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: 1,908	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	636	0	0	0	0	636
Annual IC Time Burden (Hours)	636	0	0	0	0	636
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
DVHT Grantee Reporting Reference Guide	FY21 DVHT Grantee Reporting Reference Guide_Clean.docx	09/21/2021

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.