Information Collection

Family Level Assessment and State of Home Visiting (FLASH-V) - Formative Data Collection

IC 229732 under ICR 201711-0970-008 · OMB 0970-0356.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0356 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
1 - Eligibility Assessment Form.xlsm	Other-Eligibility Assessment Form
2 - Outreach to LIAs and CIs, Assessing Eligibility, and Scheduling Interviews.docx	Other-Outreach and Scheduling
3 - Interview Protocol_LIA.docx	Other-Interview Protocol – LIA
4 - Interview Protocol_Centralized Intake Agency.docx	Other-Interview Protocol – Centraliz
FLASH-V SSA Template - Formative Generics 010918.doc FLASH-V Formative Generic - Supporting Statement A	IC Document
FLASH-V SSB Template - Formative Generics 010918.doc FLASH-V Formative Generic - Supporting Statement B	IC Document
Appendix A - Outreach to State Grantees.docx Appendix A - Outreach to State Grantees	IC Document
Appendix B - Project Description.docx Appendix B - Project Description	IC Document
Appendix C - Informed Consent.docx Appendix C - Informed Consent	IC Document

IC Title:

Family Level Assessment and State of Home Visiting (FLASH-V) - Formative Data Collection

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Other-Eligibility Assessment Form	1 - Eligibility Assessment Form.xlsm	Yes	Yes	Fillable Fileable
Other-Outreach and Scheduling	2 - Outreach to LIAs and CIs, Assessing Eligibility, and Scheduling Interviews.docx	No		Paper Only
Other-Interview Protocol â LIA	3 - Interview Protocol_LIA.docx	No		Paper Only
Other-Interview Protocol â Centralized Intake Agency	4 - Interview Protocol_Centralized Intake Agency.docx	No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 118

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	118	118
Annual IC Time Burden (Hours)	57	57
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
FLASH-V Formative Generic - Supporting Statement A	FLASH-V SSA Template - Formative Generics 010918.doc	01/12/2018
FLASH-V Formative Generic - Supporting Statement B	FLASH-V SSB Template - Formative Generics 010918.doc	01/12/2018
Appendix A - Outreach to State Grantees	Appendix A - Outreach to State Grantees.docx	01/12/2018
Appendix B - Project Description	Appendix B - Project Description.docx	01/12/2018
Appendix C - Informed Consent	Appendix C - Informed Consent.docx	01/12/2018

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