Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures

Maternal, Infant and Early Childhood Home Visiting Program Information System

Documents and Forms

Document Name Document Type
Form 3 Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures Form and Instruction
3 Home Visiting (HV) Form 3 - Tribal Grantee-defined Perfo Draft Home Visiting Form 3.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures	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	3	Home Visiting (HV) Form 3 - Tribal Grantee-defined Performance Measures	Draft Home Visiting Form 3.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 25	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	25	25
Annual IC Time Burden (Hours)	11,875	11,875
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.