2 Case Management Plan

O MB Control No:

Expiration Date:
Estimated Burden: 3 hours total

Disaster Human Services Case Management Plan

PAPERWORK REDUCTION ACT OF 1995 (Pub. L. 104-13) STATEMENT OF PUBLIC BURDEN: The purpose of this information collection is to enable ACF/OHSEPR to identify a disaster survivor’s unmet needs and provide case management support that can connect a disaster survivor to services that meet their needs. Public reporting burden for this collection of information is estimated to average a total of 3 hours per respondent, including the time for reviewing instructions, gathering and maintaining the data needed, and reviewing the collection of information. This is a voluntary collection of information. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information subject to the requirements of the Paperwork Reduction Act of 1995, unless it displays a currently valid OMB control number. The OMB # is XXXX-XXXX and the expiration date is XX/XX/20XX. If you have any comments on this collection of information, please contact the Office of Human Services Emergency Preparedness and Response, 330 C St. SW, Washington, D.C. 20201.

Instructions. The Disaster Human Services Case Management (DHSCM) Recovery Plan is intended to be completed by case managers staffing OHSEPR’s DHSCM mission. The assigned case manager completes the DHSCM Recovery Plan after assisting the disaster survivor with Sections I through IV of the Intake Assessment. The case manager should review the responses and information shared by the disaster survivor for accuracy. Then, the case manager analyzes the survivor’s information to develop this plan and identify resource referrals to meet the survivor’s unmet needs.

Disaster Survivor Information
Date of Intake			Location
Date of Plan Creation
Disaster Survivor Last Name		Disaster Survivor First Name		Disaster Survivor Middle Name
Home Phone		Mobile Phone		Email Address
Pre-Disaster Address (Street, City, State, Zip Code)
Current Address, if different (Street, City, State, Zip Code)
DHSCM Case Manager
Case Manager Last Name	Case Manager First Name				Case Manager Middle Initial
Desk Phone	Mobile Phone				Email Address
DHSCM Group Supervisor
Group Supervisor Last Name	Group Supervisor First Name				Group Supervisor Middle Initial
Desk Phone	Mobile Phone				Email Address
Reported Unmet Needs ☐ Behavioral Health ☐ Child care ☐ Disability ☐ Documentation ☐ Elder care ☐ Employment Assistance	☐ Financial Assistance ☐ Food Assistance ☐ Health Insurance ☐ Housing – Short-term ☐ Housing – Long-term ☐ Language Access				☐ Medical ☐ Medicine ☐ Utility Assistance