Information Collection

Tribal Maternal, Infant, and Early Childhood Home Visiting Program Form 4: Quarterly Performance Reporting Form

IC 250345 under ICR 202112-0970-004 · OMB 0970-0490.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0490 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Tribal Maternal, Infant, and Early Childhood Home Visiting Program Form 4: Quarterly Performance Reporting Form	Form and Instruction
4 Tribal MIECHV Quarterly Performance Reporting Form Atttachment 1 THV Form 4 - Quarterly Data Collection Form 0970-0490 .docx	Form and Instruction
4 Tribal MIECHV Quarterly Performance Reporting Form Atttachment 1 THV Form 4 - Quarterly Data Collection Form 0970-0490 .docx	Form and Instruction
Submission Tribal Home Visiting Quarterly Form 4 for PPR Gen IC (0970-0490)_11.15.21.docx Tribal MIECHV Program Form 4: Quarterly Performance Reporting	IC Document
Submission Tribal Home Visiting Quarterly Form 4 for PPR Gen IC (0970-0490)_11.15.21.docx Tribal MIECHV Program Form 4: Quarterly Performance Reporting	IC Document

IC Title:

Tribal Maternal, Infant, and Early Childhood Home Visiting Program Form 4: Quarterly Performance Reporting Form

Agency IC Tracking Number:

OCC

IC Status: Unchanged

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	4	Tribal MIECHV Quarterly Performance Reporting Form	Atttachment 1 THV Form 4 - Quarterly Data Collection Form 0970-0490 .docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 23

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	92	92
Annual IC Time Burden (Hours)	276	276
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Tribal MIECHV Program Form 4: Quarterly Performance Reporting	Submission Tribal Home Visiting Quarterly Form 4 for PPR Gen IC (0970-0490)_11.15.21.docx	11/15/2021

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