Information Collection

Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System

IC 219429 under ICR 202104-0906-005 · OMB 0906-0017.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0017 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 Performance Measurement Information System	Form and Instruction
1 Attachment A - DEMOGRAPHIC, SERVICE UTILIZATION, AND SEL Attachment A - Form 1 - Revised.docx	Form and Instruction
1 Attachment A - DEMOGRAPHIC, SERVICE UTILIZATION, AND SEL Attachment A - Form 1 - Revised.docx	Form and Instruction
2 Attachment B - PERFORMANCE AND SYSTEMS OUTCOME MEASURES Attachment B - Form 2 - Revised.docx	Form and Instruction
2 Attachment B - PERFORMANCE AND SYSTEMS OUTCOME MEASURES Attachment B - Form 2 - Revised.docx	Form and Instruction

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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 A - DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL INDICATORS	Attachment A - Form 1 - Revised.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Attachment B - PERFORMANCE AND SYSTEMS OUTCOME MEASURES	Attachment B - Form 2 - Revised.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care 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: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	44,800	2,240	42,560
Annual IC Cost Burden (Dollars)	0	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.