Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms

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⚠️ Notice: This information collection may be referencing outdated material.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 A Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms Form
A All Grantee Meeting Feedback Attachment A - All Grantee Meeting Feedback Form.docx Form
B All Grantee Meeting Individual Session Feeback Attachment B - All Grantee Meeting Individual Session Feedback Form.docx Form
Supporting Statement MIECHV AGM Feedback Forms.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program All Grantee Meeting Feedback Forms	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	A	All Grantee Meeting Feedback	Attachment A - All Grantee Meeting Feedback Form.docx		Yes	Yes	Fillable Fileable
Form	B	All Grantee Meeting Individual Session Feeback	Attachment B - All Grantee Meeting Individual Session Feedback Form.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 1,390	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	1,390	1,390
Annual IC Time Burden (Hours)	51	51
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Supporting Statement MIECHV AGM Feedback Forms.docx	12/03/2018

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