Home Visiting Program Information System

Data Collection Forms for the Maternal, Infant and Early Childhood Home Visiting Program Information System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0357 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Home Visiting Program Information System Form and Instruction
1 HV Form 1 C - HV Form 1 - Demographic and Service Utilization Data draft w public burden statement 8 1 2012.docx Form and Instruction
2 HV form 2 D - HV Form 2 - Grantee-defined performance measures w public burden statement 8-1-12.docx Form and Instruction
A - SSA Title V Section 511.docx SSA Title V Section 511 IC Document

Information Collection (IC) Details

IC Title:	Home Visiting Program Information System	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	HV Form 1	C - HV Form 1 - Demographic and Service Utilization Data draft w public burden statement 8 1 2012.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	HV form 2	D - HV Form 2 - Grantee-defined performance measures w public burden statement 8-1-12.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 81	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 Agency Discretion
Annual Number of Responses for this IC	81	81
Annual IC Time Burden (Hours)	76,739	76,739
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
SSA Title V Section 511	A - SSA Title V Section 511.docx	08/14/2012

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