Information Collection

Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies

IC 223574 under ICR 201609-0906-002 · OMB 0906-0025.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0025 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies	Form and Instruction
1 Attachment 1_Cost Tool_FINAL Attachment 1_Cost Tool_FINAL.xlsx	Form and Instruction
2 Attachment 2_Pilot Test Questionnaire_FINAL.doc Attachment 2_Pilot Test Questionnaire_FINAL.doc	Form and Instruction

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program: Cost Reporting Tool for Pilot Test in Select Local Implementing Agencies

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Attachment 1_Cost Tool_FINAL	Attachment 1_Cost Tool_FINAL.xlsx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment 2_Pilot Test Questionnaire_FINAL.doc	Attachment 2_Pilot Test Questionnaire_FINAL.doc		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 90

Number of Respondents for Small Entity: 90

Affected Public: Private Sector

Private Sector: Not-for-profit institutions

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	90	90
Annual IC Time Burden (Hours)	1,440	1,440
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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