Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Model Eligibility Review Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Model Eligibility Survey	Form and Instruction	New	Repair queued
Form 1 MIECHV Program Model Eligibility Review Survey (State/Local Government)	Form and Instruction	New	Repair queued
Form 1 Model Eligibility Survey	Form and Instruction	New	Available
Form 1 MIECHV Program Model Eligibility Review Survey (Private Sector)	Form and Instruction	New	Repair queued
Maternal Infant and Early Childhood Home Visiting Program Model Eligibility Review Survey Supporting Statement A 11.21.25.docx	Supporting Statement A	Uploaded 2025-12-12	Available
Maternal Infant and Early Childhood Home Visiting Program Model Eligibility Review Survey Supporting Statement A 11.21.25.docx	Supporting Statement A	Uploaded 2025-12-12	Repair queued
Appendix B. List of Evidence-based Home Visiting Models.pdf	Supplementary Document	Uploaded 2025-12-12	Repair queued
Appendix B. List of Evidence-based Home Visiting Models.pdf	Supplementary Document	Uploaded 2025-12-12	Repair queued
Appendix A. MIECHV Program Statute.pdf	Supplementary Document	Uploaded 2025-12-12	Repair queued
Appendix A. MIECHV Program Statute.pdf	Supplementary Document	Uploaded 2025-12-12	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
278465	MIECHV Program Model Eligibility Review Survey (State/Local Government)	Form and Instruction	New	Model Eligibility Survey
278465	MIECHV Program Model Eligibility Review Survey (State/Local Government)	Form and Instruction	New
278463	MIECHV Program Model Eligibility Review Survey (Private Sector)	Form and Instruction	New	Model Eligibility Survey
278463	MIECHV Program Model Eligibility Review Survey (Private Sector)	Form and Instruction	New

ICR Details

OMB Control No: 0906-0113	ICR Reference No: 202512-0906-002
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Model Eligibility Review Survey
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 03/03/2026
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/15/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2029	36 Months From Approved
Responses	24	0	0
Time Burden (Hours)	72	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The MIECHV program supports voluntary, evidence-based home visiting services during pregnancy and to families with young children up to kindergarten entry living in at-risk communities. One key program requirement is that programs deliver services using models that meet HHS criteria for evidence of effectiveness.1 HRSA and ACF define such service delivery models as “evidence-based.” ACF administers the Home Visiting Evidence of Effectiveness (HomVEE) review process to identify early childhood home visiting models that demonstrate evidence of effectiveness.2 However, not all evidence-based service delivery models approved through the HomVEE process meet MIECHV statutory requirements such that they may be used to carry out the MIECHV Program in fidelity to applicable program requirements. This ICR to proposes a survey to identify service delivery models that meet both HHS criteria for evidence of effectiveness, as determined by HomVEE review, and applicable MIECHV statutory requirements, and therefore may be used by eligible entities to provide home visiting services through the MIECHV Program.

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Authorizing Statute(s): PL: Pub.L. 117 - 328 6101 Name of Law: Consolidated Appropriations Act, 2023
   US Code: 42 USC 711(d)(3)(ii-iii) Name of Law: 42 USC 711: Maternal, infant, and early childhood home visiting programs
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 1508	01/08/2025
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 57770	12/12/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
MIECHV Program Model Eligibility Review Survey (Private Sector)	1	Model Eligibility Survey
MIECHV Program Model Eligibility Review Survey (State/Local Government)	1	Model Eligibility Survey

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	24	0	0	24	0	0
Annual Time Burden (Hours)	72	0	0	72	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: This is a new collection

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Annual Cost to Federal Government: $245,536

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 12/15/2025

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