Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Document Name Document Type
Form A Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys Form and Instruction
A Attachment A -Webinar Customer Satisfaction Survey Attachment A -Webinar Customer Satisfaction Survey.docx Form and Instruction
B Attachment B - Targeted TA CoP Customer Satisfaction Sur Attachment B - Targeted TA CoP Customer Satisfaction Survey.docx Form and Instruction
C Attachment C - Newsletter Issue Brief Groupsite Customer Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey.docx Form and Instruction
D Attachment D - Annual Satisfaction Survey Attachment D - Annual Satisfaction Survey.docx Form and Instruction
Supporting Statement DHVECS HV-ImpACT TA Surveys FINAL.docx Supporting Statement IC Document

Information Collection (IC) Details

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program HV-ImpACT Technical Assistance Program Feedback and Satisfaction Surveys	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	A	Attachment A -Webinar Customer Satisfaction Survey	Attachment A -Webinar Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	B	Attachment B - Targeted TA CoP Customer Satisfaction Survey	Attachment B - Targeted TA CoP Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	C	Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey	Attachment C - Newsletter Issue Brief Groupsite Customer Satisfaction Survey.docx	Yes	Yes	Fillable Fileable
Form and Instruction	D	Attachment D - Annual Satisfaction Survey	Attachment D - Annual Satisfaction Survey.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 753	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	753	753
Annual IC Time Burden (Hours)	322	322
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement	Supporting Statement DHVECS HV-ImpACT TA Surveys FINAL.docx	02/13/2017

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