Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys

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

OMB: 0915-0212

IC ID: 247043

⚠️ Notice: This information collection may be referencing outdated material.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 1 Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys Form
1 Attachment A_Individualized Targeted TA Check in Attachment A_Individualized Targeted TA Check in.docx Form
1 Attachment A_Individualized Targeted TA Check in Attachment A_Individualized Targeted TA Check in.docx Form
2 Attachment B_Individualized Targeted TA Closeout Attachment B_Individualized Targeted TA Closeout.docx Form
2 Attachment B_Individualized Targeted TA Closeout Attachment B_Individualized Targeted TA Closeout.docx Form
3 Attachment C_Project Officer Survey Attachment C_Project Officer Survey.docx Form
3 Attachment C_Project Officer Survey Attachment C_Project Officer Survey.docx Form
4 Attachment D_Webinar Survey Attachment D_Webinar Survey.docx Form
4 Attachment D_Webinar Survey Attachment D_Webinar Survey.docx Form
5 Attachment E_Community of Practice Survey Attachment E_Community of Practice Survey.docx Form
5 Attachment E_Community of Practice Survey Attachment E_Community of Practice Survey.docx Form
6 Attachment F_Leadership Academy Session Survey Attachment F_Leadership Academy Session Survey.docx Form
6 Attachment F_Leadership Academy Session Survey Attachment F_Leadership Academy Session Survey.docx Form
7 Attachment G_Leadership Academy Completion Survey Attachment G_Leadership Academy Completion Survey.docx Form
7 Attachment G_Leadership Academy Completion Survey Attachment G_Leadership Academy Completion Survey.docx Form
8 Attachment H_Quarterly Overall TA Survey Attachment H_Quarterly Overall TA Survey.docx Form
8 Attachment H_Quarterly Overall TA Survey Attachment H_Quarterly Overall TA Survey.docx Form
9 Attachment I_CQI Practicum Check in Survey Attachment I_CQI Practicum Check in Survey.docx Form
9 Attachment I_CQI Practicum Check in Survey Attachment I_CQI Practicum Check in Survey.docx Form
10 Attachment J_CQI Practicum Completion Survey Attachment J_CQI Practicum Completion Survey.docx Form
10 Attachment J_CQI Practicum Completion Survey Attachment J_CQI Practicum Completion Survey.docx Form
Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys.docx Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys IC Document
Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys.docx Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program Technical Assistance Resource Center (TARC) Satisfaction Surveys	Agency IC Tracking Number:

IC Status: Unchanged

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	1	Attachment A_Individualized Targeted TA Check in	Attachment A_Individualized Targeted TA Check in.docx	Yes	Yes	Fillable Fileable
Form	2	Attachment B_Individualized Targeted TA Closeout	Attachment B_Individualized Targeted TA Closeout.docx	Yes	Yes	Fillable Fileable
Form	3	Attachment C_Project Officer Survey	Attachment C_Project Officer Survey.docx	Yes	Yes	Fillable Fileable
Form	4	Attachment D_Webinar Survey	Attachment D_Webinar Survey.docx	Yes	Yes	Fillable Fileable
Form	5	Attachment E_Community of Practice Survey	Attachment E_Community of Practice Survey.docx	Yes	Yes	Fillable Fileable
Form	6	Attachment F_Leadership Academy Session Survey	Attachment F_Leadership Academy Session Survey.docx	Yes	Yes	Fillable Fileable
Form	7	Attachment G_Leadership Academy Completion Survey	Attachment G_Leadership Academy Completion Survey.docx	Yes	Yes	Fillable Fileable
Form	8	Attachment H_Quarterly Overall TA Survey	Attachment H_Quarterly Overall TA Survey.docx	Yes	Yes	Fillable Fileable
Form	9	Attachment I_CQI Practicum Check in Survey	Attachment I_CQI Practicum Check in Survey.docx	Yes	Yes	Fillable Fileable
Form	10	Attachment J_CQI Practicum Completion Survey	Attachment J_CQI Practicum Completion Survey.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: 2,230	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Previously Approved
Annual Number of Responses for this IC	2,230	2,230
Annual IC Time Burden (Hours)	209	209
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys	Supporting Statement DHVECS MIECHV TARC Satisfaction Surveys.docx	04/28/2021

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