Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form

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⚠️ Notice: This information collection may be referencing outdated material.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 1 Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form Form
1 MIECHV On-Site Compliance Review Awardee Feedback Form.d FORM MIECHV On-Site Compliance Review Awardee Feedback Form.docx Form
Supporting Statement A MIECHV Compliance.docx Supporting Statement A MIECHV Compliance IC Document

Information Collection (IC) Details

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program (MIECHV) On-Site Compliance Review Awardee Feedback Form	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	1	MIECHV On-Site Compliance Review Awardee Feedback Form.docx	FORM MIECHV On-Site Compliance Review Awardee 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: 165	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	165	165
Annual IC Time Burden (Hours)	41	41
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement A MIECHV Compliance	Supporting Statement A MIECHV Compliance.docx	09/22/2020

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