Information Collection

Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service

IC 221921 under ICR 202201-0970-011 · OMB 0970-0389.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0389 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service	Form and Instruction
1 Demographic and Service Utilization Data and Service Tribal MIECHV Form 1 CLEAN.docx	Form and Instruction
1 Demographic and Service Utilization Data and Service Tribal MIECHV Form 1 CLEAN.docx	Form and Instruction

IC Title:

Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service

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	Demographic and Service Utilization Data and Service	Tribal MIECHV Form 1 CLEAN.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: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	23	-2	25
Annual IC Time Burden (Hours)	11,500	-1,000	12,500
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.