Information Collection

Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys

IC 232942 under ICR 202012-0915-001 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form A Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys	Form
A Attachment A - HV-PMCQI Annual Survey.docx Attachment A - HV-PMCQI Annual Survey.docx	Form
B Attachment B - HV-PMCQI Information Request Survey.docx Attachment B - HV-PMCQI Information Request Survey.docx	Form
C Attachment C - HV-PMCQI Individualized TA Survey.docx Attachment C - HV-PMCQI Individualized TA Survey.docx	Form
D Attachment D - HV-PMCQI Webinar Survey.docx Attachment D - HV-PMCQI Webinar Survey.docx	Form
Supporting Statement DHVECS HV-PMCQI Surveys_2018_FINAL.docx Supporting Statement A	IC Document

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program HV-PM/CQI Technical Assistance Center Satisfaction Surveys

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	A	Attachment A - HV-PMCQI Annual Survey.docx	Attachment A - HV-PMCQI Annual Survey.docx	Yes	Yes	Fillable Fileable
Form	B	Attachment B - HV-PMCQI Information Request Survey.docx	Attachment B - HV-PMCQI Information Request Survey.docx	Yes	Yes	Fillable Fileable
Form	C	Attachment C - HV-PMCQI Individualized TA Survey.docx	Attachment C - HV-PMCQI Individualized TA Survey.docx	Yes	Yes	Fillable Fileable
Form	D	Attachment D - HV-PMCQI Webinar Survey.docx	Attachment D - HV-PMCQI Webinar Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,150

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Requested	Previously Approved
Annual Number of Responses for this IC	1,150	1,150
Annual IC Time Burden (Hours)	112	112
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Supporting Statement A	Supporting Statement DHVECS HV-PMCQI Surveys_2018_FINAL.docx	09/07/2018

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