Information Collection

Home Visiting Program Information System

IC 203751 under ICR 201208-0915-005 · OMB 0915-0357.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

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	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 %

table that charts list of burden
	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

table that charts IC Documents
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.