Information Collection

Healthy Start Program Survey Instruments

IC 257575 under ICR 202212-0906-002 · OMB 0906-0076.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0076 can be found here:

2023-09-08 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Attachment A2_HS Recruitment Email Program Survey.docx	Instruction
Attachment A2_HS Recruitment Email Program Survey.docx	Instruction
Attachment A3_HS Recruitment Email Network Survey.docx	Instruction
Attachment A3_HS Recruitment Email Network Survey.docx	Instruction
Attachment A4_HS Recruitment Email Participant Survey.docx	Instruction
Attachment A4_HS Recruitment Email Participant Survey.docx	Instruction
Attachment A5_HS Recruitment Email Participant Survey-Spanish.docx	Instruction
Attachment A5_HS Recruitment Email Participant Survey-Spanish.docx	Instruction
Attachment A6_HS Recruitment Email Stakeholder Interview Guide.docx	Instruction
Attachment A6_HS Recruitment Email Stakeholder Interview Guide.docx	Instruction
Attachment B7_HS Program Survey_FAQs.docx	Instruction
Attachment B7_HS Program Survey_FAQs.docx	Instruction
Attachment B8_HS Network Survey_FAQs.docx	Instruction
Attachment B8_HS Network Survey_FAQs.docx	Instruction
1 Program Survey Attachment B1_HS Program Survey (003).docx	Form and Instruction
1 Program Survey Attachment B1_HS Program Survey (003).docx	Form and Instruction
2 Network Survey Attachment B2_HS Network Survey.docx	Form and Instruction
2 Network Survey Attachment B2_HS Network Survey.docx	Form and Instruction
3 Participant Survey Attachment B3_HS Participant Survey.docx	Form and Instruction
3 Participant Survey Attachment B3_HS Participant Survey.docx	Form and Instruction
5 Stakeholder Interview Attachment B5_HS Stakeholder Interview Guide.docx	Form and Instruction
5 Stakeholder Interview Attachment B5_HS Stakeholder Interview Guide.docx	Form and Instruction
4 Participant Survey Spanish Attachment B4_HS Participant Survey-Spanish.docx	Form and Instruction
4 Participant Survey Spanish Attachment B4_HS Participant Survey-Spanish.docx	Form and Instruction
6 Results and Recommendations Attachment B6_Pilot Survey Results and Recommendations.docx	Form and Instruction
6 Results and Recommendations Attachment B6_Pilot Survey Results and Recommendations.docx	Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Healthy Start Program Survey Instruments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

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
Instruction			Attachment A2_HS Recruitment Email Program Survey.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment A3_HS Recruitment Email Network Survey.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment A4_HS Recruitment Email Participant Survey.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment A5_HS Recruitment Email Participant Survey-Spanish.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment A6_HS Recruitment Email Stakeholder Interview Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1	Program Survey	Attachment B1_HS Program Survey (003).docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	Network Survey	Attachment B2_HS Network Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	Participant Survey	Attachment B3_HS Participant Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	Stakeholder Interview	Attachment B5_HS Stakeholder Interview Guide.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	Participant Survey Spanish	Attachment B4_HS Participant Survey-Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	Results and Recommendations	Attachment B6_Pilot Survey Results and Recommendations.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment B7_HS Program Survey_FAQs.docx	Yes	Yes	Fillable Fileable
Instruction			Attachment B8_HS Network Survey_FAQs.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 1,601

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
Annual Number of Responses for this IC	1,601	1,601
Annual IC Time Burden (Hours)	600	600
Annual IC Cost Burden (Dollars)	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.