1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN

Multi-Site Implementation Evaluation of Tribal Home Visiting

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0521 can be found here:

Documents and Forms

Document Name Document Type
1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN.docx Other-Enrollment Form

Information Collection (IC) Details

IC Title:	1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN	Agency IC Tracking Number:

Is this a Common Form? No		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
Other-Enrollment Form			1. MUSE Caregiver Enrollment Form 7.9.18_CLEAN.docx		No		Paper Only

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 31	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	434	434
Annual IC Time Burden (Hours)	35	35
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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