Information Collection

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

IC 225692 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⚠️ Notice: This information collection may be referencing outdated material.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 A Attachment A -Webinar Customer Satisfaction Survey Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction
Form B Attachment B - Targeted TA CoP Customer Satisfaction Survey Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction
Form C Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction
Form D Attachment D - Annual Satisfaction Survey Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Form and Instruction
A Attachment A -Webinar Customer Satisfaction Survey Attachment A -Webinar Customer Satisfaction Survey.docx	Form and Instruction
B Attachment B - Targeted TA CoP Customer Satisfaction Sur Attachment B - Targeted TA CoP Customer Satisfaction Survey.docx	Form and Instruction
C Attachment C - Newsletter Issue Brief Groupsite Customer Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey.docx	Form and Instruction
D Attachment D - Annual Satisfaction Survey Attachment D - Annual Satisfaction Survey.docx	Form and Instruction
Supporting Statement DHVECS HV-ImpACT TA Surveys FINAL.docx Supporting Statement	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program 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	A	Attachment A -Webinar Customer Satisfaction Survey	Attachment A -Webinar Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B	Attachment B - Targeted TA CoP Customer Satisfaction Survey	Attachment B - Targeted TA CoP Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	C	Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey	Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	D	Attachment D - Annual Satisfaction Survey	Attachment D - Annual Satisfaction Survey.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 753

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	753	753
Annual IC Time Burden (Hours)	322	322
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement	Supporting Statement DHVECS HV-ImpACT TA Surveys FINAL.docx	02/13/2017

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