Information Collection

Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys

IC 221518 under ICR 201502-0915-002 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form B Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys	Form and Instruction
B Attachement B - Town Hall Satisfaction Survey Attachement B - Town Hall Satisfaction Survey.docx	Form and Instruction
C Attachment C - All Grantee Meeting Assessment Form Indiv Attachment C - All Grantee Meeting Assessment Form Individual Session.docx	Form and Instruction
D Attachment D - All Grantee Meeting Assessment Form Overa Attachment D - All Grantee Meeting Assessment Form Overall.docx	Form and Instruction
E Attachment E - Site Visit Assessment Form Attachment E - Site Visit Assessment Form.pdf	Form and Instruction
Attachment A - Supporting Statement MIECHV TA Feedback.docx Attachment A - Supporting Statement	IC Document

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Feedback and Satisfaction Surveys

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	B	Attachement B - Town Hall Satisfaction Survey	Attachement B - Town Hall Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	C	Attachment C - All Grantee Meeting Assessment Form Individual Session	Attachment C - All Grantee Meeting Assessment Form Individual Session.docx	Yes	Yes	Fillable Fileable
Form and Instruction	D	Attachment D - All Grantee Meeting Assessment Form Overall	Attachment D - All Grantee Meeting Assessment Form Overall.docx	Yes	Yes	Fillable Fileable
Form and Instruction	E	Attachment E - Site Visit Assessment Form	Attachment E - Site Visit Assessment Form.pdf	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,650

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	1,650	1,650
Annual IC Time Burden (Hours)	508	508
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Attachment A - Supporting Statement	Attachment A - Supporting Statement MIECHV TA Feedback.docx	05/13/2016

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