Case Record Notes – Case Manager

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

Documents and Forms

Document Name Document Type
Form 4 Case Record Notes – Case Manager Form and Instruction
4 Case Record Notes 3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx Form and Instruction
4 Case Record Notes 3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Case Record Notes – Case Manager	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

Obligation to Respond: Voluntary

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	4	Case Record Notes	3 and 4 - ACF OHSEPR DHSCM Case Management Referral Form and Case Record Notes.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title: OHESPR Repatriation and Disaster Human Services Case Management Records	FR Citation: 88 FR 63109

Number of Respondents: 180	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 95 %

	Approved	Previously Approved
Annual Number of Responses for this IC	9,000	9,000
Annual IC Time Burden (Hours)	9,000	9,000
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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