Information Collection

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

IC 230844 under ICR 202011-0970-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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-Assessment Form
2 - Outreach to LIAs and CIs, Assessing Eligibility, and Scheduling Interviews.docx	Other-Outreach
3 - Interview Protocol_LIA.docx	Other-Interview Protocol
4 - Interview Protocol_Centralized Intake Agency.docx	Other-Interview Protocol
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
FLASH-V SSA Template - Formative Generics 010918.doc SSA - FLASHV Formative	IC Document
FLASH-V SSB Template - Formative Generics 010918.doc SSB - FLASHV	IC Document
FLASH-V Formative_NOA_1.19.18.pdf NOA - FLASHV Generic	IC Document

IC Title:

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

Agency IC Tracking Number:

IC Status: Unchanged

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-Assessment Form	1 - Eligibility Assessment Form.xlsm	Yes	Yes	Fillable Fileable
Other-Outreach	2 - Outreach to LIAs and CIs, Assessing Eligibility, and Scheduling Interviews.docx	Yes	Yes	Fillable Fileable
Other-Interview Protocol	3 - Interview Protocol_LIA.docx	No		Paper Only
Other-Interview Protocol	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
	Requested	Previously Approved
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
Appendix A - Outreach to State Grantees	Appendix A - Outreach to State Grantees.docx	03/28/2018
Appendix B - Project Description	Appendix B - Project Description.docx	03/28/2018
Appendix C - Informed Consent	Appendix C - Informed Consent.docx	03/28/2018
SSA - FLASHV Formative	FLASH-V SSA Template - Formative Generics 010918.doc	03/28/2018
SSB - FLASHV	FLASH-V SSB Template - Formative Generics 010918.doc	03/28/2018
NOA - FLASHV Generic	FLASH-V Formative_NOA_1.19.18.pdf	03/28/2018

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