Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System

Documents and Forms

Document Name Document Type
Form 1 Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System Form and Instruction
1 DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL IN Appendix A. Form 1.docx Form and Instruction
1 DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL IN Appendix A. Form 1 09092024.docx Form and Instruction
2 PERFORMANCE AND SYSTEMS OUTCOME MEASURES Appendix B. Form 2.docx Form and Instruction
2 PERFORMANCE AND SYSTEMS OUTCOME MEASURES Appendix B. Form 2 09092024.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Maternal, Infant, and Early Childhood Home Visiting Program Performance Measurement Information System	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	1	DEMOGRAPHIC, SERVICE UTILIZATION, AND SELECT CLINICAL INDICATORS	Appendix A. Form 1 09092024.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	PERFORMANCE AND SYSTEMS OUTCOME MEASURES	Appendix B. Form 2 09092024.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 56	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	Previously Approved
Annual Number of Responses for this IC	56	0	56
Annual IC Time Burden (Hours)	43,736	-1,064	44,800
Annual IC Cost Burden (Dollars)	0	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.