Instrument 1: Request for LIA Contact Information from MIECHV Leads

Family Level Assessment and State of Home Visiting (FLASH-V) Outreach and Recruitment Study

Documents and Forms

Document Name Document Type
Instrument 1_Request for LIA Contact Information from MIECHV Leads.docx Other-Request for LIA Contact Inform
Instrument 1_Request for LIA Contact Information from MIECHV Leads.docx Other-Request for LIA Contact Inform

Information Collection (IC) Details

IC Title:	Instrument 1: Request for LIA Contact Information from MIECHV Leads	Agency IC Tracking Number:

Is this a Common Form? No		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
Other-Request for LIA Contact Information from MIECHV Lead			Instrument 1_Request for LIA Contact Information from MIECHV Leads.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	28	28
Annual IC Time Burden (Hours)	7	7
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.