Information Collection

Supplemental Information Request for the Submission of the Updated State Plan for A State Home Visiting Program

IC 196112 under ICR 201107-0915-002 · OMB 0915-0336.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Supplemental Information Request for the Submission of the Updated State Plan for A State Home Visiting Program	Form and Instruction
1 SIR HRSA_Home_Visiting_2nd SIR FINAL 2011.docx	Form and Instruction

IC Title:

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:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	SIR	HRSA_Home_Visiting_2nd SIR FINAL 2011.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 56

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	56	56
Annual IC Time Burden (Hours)	15,176	15,176
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
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.