Form B Attachment B - HV-PMCQI Information Request Survey

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

Attachment B - HV-PMCQI Information Request Survey

Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys

OMB: 0915-0212

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OMB No: 0915-0212

Expiration date: 07/31/2021


HV-PM/CQI TA Center Information Request Survey


Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0915-0212. Public reporting burden for this collection of information is estimated to average .08 hours per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 14N136B, Rockville, Maryland, 20857.


  1. How helpful was the content provided by your TA Specialist in addressing your technical assistance need(s)?

    • Extremely helpful

    • Very helpful

    • Moderately helpful

    • Slightly helpful

    • Not at all helpful


  1. [If respondent chooses options c-f in #1] How could your TA Specialist’s technical assistance have been more helpful in addressing your needs with this request?


  1. What is your state/territory?

    1. Dropdown list of 56 states/territories plus an N/A option

File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorMcAuley, Emma
File Modified0000-00-00
File Created2021-01-20

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