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

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

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:

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 %

	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

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.