Family Online Survey

Home Visiting Assessment of Implementation Quality Study: Better Addressing Disparities Through Home Visiting

Documents and Forms

Document Name Document Type
Form 3 Family Online Survey Form and Instruction
3 Family Online Survey Appendix F_Disparities Instrument 3_ Family Online Survey.docx Form and Instruction
3 Family Online Survey Appendix F_Disparities Instrument 3_ Family Online Survey 08012024.docx Form and Instruction
Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx Appendix F_Disparities Instrument 3_ Family Online Survey (RL) IC Document

Information Collection (IC) Details

IC Title:	Family Online Survey	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
Form and Instruction	3	Family Online Survey	Appendix F_Disparities Instrument 3_ Family Online Survey 08012024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 210	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	210	210
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Appendix F_Disparities Instrument 3_ Family Online Survey (RL)	Appendix D_Disparities Instrument 1_Request for Information about LIAs (RL).docx	08/01/2024

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