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Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form
Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration
OMB: 0915-0212
IC ID: 264351
OMB.report
HHS/HSA
OMB 0915-0212
ICR 202401-0915-004
IC 264351
( )
Documents and Forms
Document Name
Document Type
Form 1
Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form
Form
1 On Site Compliance Review Awardee Feedback Form
FORM MIECHV On-Site Compliance Review Awardee Feedback Form_May202.docx
Form
1 On Site Compliance Review Awardee Feedback Form
FORM MIECHV On-Site Compliance Review Awardee Feedback Form_May202.docx
Form
SS A MIECHV onsite Compliance Review Awardee Feedback Form -Ma.docx
Original Generic Request
IC Document
SS A MIECHV onsite Compliance Review Awardee Feedback Form -Ma.docx
Original Generic Request
IC Document
Information Collection (IC) Details
View Information Collection (IC)
IC Title:
Maternal, Infant, and Early Childhood Home Visiting Program On-Site Compliance Review Awardee Feedback Form
Agency IC Tracking Number:
IC Status:
New
Obligation to Respond:
Voluntary
CFR Citation:
Information Collection Instruments:
Document Type
Form No.
Form Name
Instrument File
URL
Available Electronically?
Can Be Submitted Electronically?
Electronic Capability
Form
1
On Site Compliance Review Awardee Feedback Form
FORM MIECHV On-Site Compliance Review Awardee Feedback Form_May202.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:
315
Number of Respondents for Small Entity:
0
Affected Public:
State, Local, and Tribal Governments
Percentage of Respondents Reporting Electronically:
100 %
Requested
Program Change Due to New Statute
Program Change Due to Agency Discretion
Change Due to Adjustment in Agency Estimate
Change Due to Potential Violation of the PRA
Previously Approved
Annual Number of Responses for this IC
315
0
315
0
0
0
Annual IC Time Burden (Hours)
79
0
79
0
0
0
Annual IC Cost Burden (Dollars)
0
0
0
0
0
0
Documents for IC
Title
Document
Date Uploaded
Original Generic Request
SS A MIECHV onsite Compliance Review Awardee Feedback Form -Ma.docx
01/09/2024
Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.