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

Tribal Maternal, Infant, and Early Childhood Home Visiting Program Form 1: Demographic and Service Utilization Data

Documents and Forms

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 - NonSub 4-29-22 Clean.docx Form and Instruction
1 Demographic and Service Utilization Data and Service Tribal MIECHV Form 1 - NonSub 4-29-22 Clean.docx Form and Instruction

Information Collection (IC) Details

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:

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 - NonSub 4-29-22 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 %

	Approved	Previously Approved
Annual Number of Responses for this IC	23	23
Annual IC Time Burden (Hours)	11,500	11,500
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.