Information Collection

Maternal, Infant, and Early Childhood Home Visiting Program Quarterly Performance Report

IC 218304 under ICR 202110-0906-001 · OMB 0906-0016.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0016 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 Quarterly Performance Report	Form and Instruction
Attachment A _MIECHV Form 4 TRACKED.docx	Other-Tracked Changes
Attachment A _MIECHV Form 4 TRACKED.docx	Other-Tracked Changes
1 MIECHV Form 4 Revised CLEAN.docx Attachment A _MIECHV Form 4 Revised CLEAN.docx	Form and Instruction
1 MIECHV Form 4 Revised CLEAN.docx Attachment A _MIECHV Form 4 Revised CLEAN.docx	Form and Instruction
1 Updated Attachment A _MIECHV Form 4 Revised Updates 11-22-21.doc Attachment A _MIECHV Form 4 Revised_updates.docx	Form and Instruction

IC Title:

Maternal, Infant, and Early Childhood Home Visiting Program Quarterly Performance Report

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	MIECHV Form 4 Revised CLEAN.docx	Attachment A _MIECHV Form 4 Revised CLEAN.docx	Yes	Yes	Fillable Fileable
Other-Tracked Changes			Attachment A _MIECHV Form 4 TRACKED.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1 Updated	Attachment A _MIECHV Form 4 Revised Updates 11-22-21.docx	Attachment A _MIECHV Form 4 Revised_updates.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	488	224	264
Annual IC Time Burden (Hours)	18,752	5,376	13,376
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.