Information Collection

Home Visitor Group Interview Protocol

IC 267049 under ICR 202404-0906-005 · OMB 0906-0099.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 5 Home Visitor Group Interview Protocol	Form and Instruction
5 Home Visitor Group Interview Guide Appendix H_Instrument 5_Home Visitor Group Interview Guide.docx	Form and Instruction
5 Home Visitor Group Interview Guide Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide 08012024.docx	Form and Instruction
Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide (RL).docx Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide (RL)	IC Document

IC Title:

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	5	Home Visitor Group Interview Guide	Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide 08012024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 10

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	10	10
Annual IC Time Burden (Hours)	15	15
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide (RL)	Appendix H_Disparities Instrument 5_Home Visitor Group Interview Guide (RL).docx	08/01/2024

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