OMB control number

Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System

OMB 0906-0017 · HHS/HRSA.

OMB 0906-0017

The Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program is administered by the Maternal and Child Health Bureau (MCHB) within HRSA in partnership with the Administration for Children and Families. MIECHV provides support to all 56 states and jurisdictions, as well as tribes and tribal organizations. State and jurisdiction MIECHV funding recipients report annual demographic and performance data to HRSA through: Form 1 – Demographic Performance Measures; Form 2 – Benchmark Performance Measures. MIECHV funding recipients also report program information on a quarterly basis through Form 4 – Quarterly Data Collection, currently approved under OMB No. 0906-0016. This ICR will now include Forms 1, 2, and 4, so all the components of data collection for the MIECHV Program in one request. OMB No. 0906-0016 will be discontinued after OMB approval of this ICR. The forms will not be renumbered because MIECHV used to have Form 3 and that is no longer part of the data collection. MCHB decided not to renumber the forms because this has been well recognized by all awardees that it’s the quarterly form and renaming to Form 3 might be more confusing at this time.

The latest form for Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System expires 2029-05-31 and is listed under ICR 202603-0906-002.

Latest Forms, Documents, and Supporting Material

Latest forms, documents, and information collections
DocumentType
Form 4 Quarterly Performance ReportForm and Instruction
Form 4 Quarterly Performance ReportForm and Instruction
Form 2 Performance Indicators and Systems Outcome MeasuresForm and Instruction
Form 2 Performance Indicators and Systems Outcome MeasuresForm and Instruction
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program LocationsForm and Instruction
Form 1 Demographic, Service Utilization, Select Clinical Indicators, and Program LocationsForm and Instruction
Supporting Statement A-0906-0017-MCHB-MIECHV Performance Measures 04162026.docxSupporting Statement A
Supporting Statement A-0915-0017-MCHB-MIECHV Performance Measures 03062026.docxSupporting Statement A
Quarterly Performance Report Form and Instruction
Quarterly Performance Report Form and Instruction
Quarterly Performance Report Form and Instruction
Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction
Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures Form and Instruction

OMB Details

Annual Reporting: Demographic Service Utilization, Clinical Indicators, and Program Locations; Performance Indicators and Systems Outcome Measures

Federal Enterprise Architecture: Health - Health Care Services

Information collection instruments
FormNameElectronic accessType
Form 1Demographic, Service Utilization, Select Clinical Indicators, and Program LocationsFillable FileableForm and instruction
Form 2Performance Indicators and Systems Outcome MeasuresFillable FileableForm and instruction

Review document collections for all forms, instructions, and supporting documents - including paper/printable forms.