Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center 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⚠️ Notice: This information collection may be referencing outdated material.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 HV-PM/CQI Technical Assistance Center Satisfaction Surveys Form
A Attachment A - HV-PMCQI Annual Survey.docx Attachment A - HV-PMCQI Annual Survey.docx Form
B Attachment B - HV-PMCQI Information Request Survey.docx Attachment B - HV-PMCQI Information Request Survey.docx Form
C Attachment C - HV-PMCQI Individualized TA Survey.docx Attachment C - HV-PMCQI Individualized TA Survey.docx Form
D Attachment D - HV-PMCQI Webinar Survey.docx Attachment D - HV-PMCQI Webinar Survey.docx Form
Supporting Statement DHVECS HV-PMCQI Surveys_2018_FINAL.docx Supporting Statement A IC Document

Information Collection (IC) Details

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center 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	B	Attachment B - HV-PMCQI Information Request Survey.docx	Attachment B - HV-PMCQI Information Request Survey.docx	Yes	Yes	Fillable Fileable
Form	C	Attachment C - HV-PMCQI Individualized TA Survey.docx	Attachment C - HV-PMCQI Individualized TA Survey.docx	Yes	Yes	Fillable Fileable
Form	D	Attachment D - HV-PMCQI Webinar Survey.docx	Attachment D - HV-PMCQI Webinar Survey.docx	Yes	Yes	Fillable Fileable
Form	A	Attachment A - HV-PMCQI Annual Survey.docx	Attachment A - HV-PMCQI Annual Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,150	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	1,150	1,150
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A	Supporting Statement DHVECS HV-PMCQI Surveys_2018_FINAL.docx	09/07/2018

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