Pay for Outcomes Workplan Timeline Template

Maternal, Infant, and Early Childhood Home Visiting Program Pay for Outcomes Supplemental Information Request (PFO)

Documents and Forms

Document Name Document Type
Form 1 Pay for Outcomes Workplan Timeline Template Form and Instruction
FORM - PFO SIR Guidance.docx Instruction
FORM - PFO SIR Guidance.docx Instruction
1 FORM - PFO Workplan Timeline Template.xlsx FORM - PFO Workplan Timeline Template.xlsx Form and Instruction
1 FORM - PFO Workplan Timeline Template.xlsx FORM - PFO Workplan Timeline Template.xlsx Form and Instruction

Information Collection (IC) Details

IC Title:	Pay for Outcomes Workplan Timeline Template	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
Form and Instruction	1	FORM - PFO Workplan Timeline Template.xlsx	FORM - PFO Workplan Timeline Template.xlsx		Yes	Yes	Fillable Fileable
Instruction			FORM - PFO SIR Guidance.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 15	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	15	15
Annual IC Time Burden (Hours)	1,380	1,380
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.