Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators

Surveys of State, Tribal, Local and Territorial (STLT) Governmental Health Agencies

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0879 can be found here:

Documents and Forms

Document Name Document Type
Form 0920-0879 Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators Form and Instruction
EHDI- Attachment E- Introductory Email.docx Instruction
EHDI- Attachment F- Reminder Email.docx Instruction
0920-0879 EHDI- Attachment C- Data Collection Instrument web versi EHDI- Attachment C- Data Collection Instrument web version.docx Form and Instruction
0920-0879 EHDI- Attachment D- Data Collection Instrument Word vers EHDI- Attachment D- Data Collection Instrument Word version.docx Form and Instruction
0920-0879 EHDI- Attachment G- Self Assessment Follow up EHDI- Attachment G- Self Assessment Follow up.docx Form and Instruction
EHDI- Attachment A- EHDI-IS Cooperative Agreement.docx EHDI- Attachment A- EHDI-IS Cooperative Agreement IC Document
EHDI Supporting Statement Part A v031113.docx EHDI Supporting Statement Part A v031113 IC Document
EHDI Supporting Statement Part B 031113.docx EHDI Supporting Statement Part B 031113 IC Document

Information Collection (IC) Details

IC Title:	Assessment of Evaluation Capacity among State and Territorial Early Hearing Detection and Intervention (EHDI) Program Coodinators	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	0920-0879	EHDI- Attachment C- Data Collection Instrument web version	EHDI- Attachment C- Data Collection Instrument web version.docx	Yes	Yes	Fillable Fileable
Instruction			EHDI- Attachment E- Introductory Email.docx	Yes	Yes	Printable Only
Form and Instruction	0920-0879	EHDI- Attachment D- Data Collection Instrument Word version	EHDI- Attachment D- Data Collection Instrument Word version.docx	Yes	Yes	Fillable Fileable
Instruction			EHDI- Attachment F- Reminder Email.docx	Yes	Yes	Printable Only
Form and Instruction	0920-0879	EHDI- Attachment G- Self Assessment Follow up	EHDI- Attachment G- Self Assessment Follow up.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 52	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	52	0	0	0	0	0
Annual IC Time Burden (Hours)	13	0	0	0	0	0
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

Title	Document	Date Uploaded
EHDI- Attachment A- EHDI-IS Cooperative Agreement	EHDI- Attachment A- EHDI-IS Cooperative Agreement.docx	03/14/2013
EHDI Supporting Statement Part A v031113	EHDI Supporting Statement Part A v031113.docx	03/14/2013
EHDI Supporting Statement Part B 031113	EHDI Supporting Statement Part B 031113.docx	03/14/2013

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