3 Resource Referral Form

O MB Control No:

Expiration Date:
Estimated Burden: 4 hours

Disaster Human Services Case Management Referral Form

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 4 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.

Referral Type ☐ Behavioral Health ☐ Child Care ☐ Clothing ☐ Disability ☐ Elder Care ☐ Employment	☐ Federal Disaster Assistance ☐ Financial Assistance ☐ Food Assistance ☐ Health Insurance ☐ Housing – Short-term ☐ Housing – Long-term	☐ Legal Services ☐ Medical ☐ Pharmacist ☐ State human services ☐ Veteran assistance ☐ Other________________
Resource Provider (Name)
Resource Provider Address (Street, City, State, Zip Code)
Point of Contact, if applicable
Office Phone	Cell Phone	Email Address
Current Business Hours	Appointment Date	Appointment Time
Directions to Resource Provider
Notes
Referral Result
☐ Information Only ☐ Eligibility for Resource Provider Pending ☐ Eligible for Resource Provider ☐ Ineligible for Resource Provider ☐ Needs Met – Resource Provided ☐ Needs Unmet ☐ No Show ☐ Declined referral

Disaster Human Services Case Management Case Record Notes

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 4 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.

Entry Date:
Purpose: ☐General Note ☐Close Record
Entry Date:
Purpose: ☐General Note ☐Close Record
Entry Date:
Purpose: ☐General Note ☐Close Record
Entry Date:
Purpose: ☐General Note ☐Close Record
Entry Date:
Purpose: ☐General Note ☐Close Record
Case Closure	Reasons for Closure (select all that apply)
Date of Closure:	☐Survivor completed their case management goals ☐Survivor identified outside resources and no longer needs assistance ☐Survivor was referred to another program that provides comparable case management services ☐Survivor chose to end participation in the program ☐Survivor cannot be reached at their provided ☐address, ☐phone, or ☐ email