Barriers to Service Delivery and Monitoring Form

Domestic Victims of Human Trafficking Program Data

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0542 can be found here:

Documents and Forms

Document Name Document Type
Form 4 Barriers to Service Delivery and Monitoring Form Form
4 Barriers to Service Delivery and Monitoring Form 4 - OTIP-0564 - DVHT New - Barriers to Service Delivery and Monitoring Form CLEAN.pdf Form
DVHT Grantee Reporting Reference Guide_1.21.20.docx DVHT Grantee Reporting Reference Guide IC Document

Information Collection (IC) Details

IC Title:	Barriers to Service Delivery and Monitoring Form	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	4	Barriers to Service Delivery and Monitoring Form	4 - OTIP-0564 - DVHT New - Barriers to Service Delivery and Monitoring Form CLEAN.pdf		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 36	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	30	30
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
DVHT Grantee Reporting Reference Guide	DVHT Grantee Reporting Reference Guide_1.21.20.docx	01/23/2020

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