MIECHV Program Model Eligibility Review Survey (State/Local Government)

Maternal, Infant, and Early Childhood Home Visiting (MIECHV) Program Model Eligibility Review Survey

Documents and Forms

Document Name Document Type
Form 1 MIECHV Program Model Eligibility Review Survey (State/Local Government) Form and Instruction
1 Model Eligibility Survey Appendix C. Model Eligibility Review Survey.docx Form and Instruction

Information Collection (IC) Details

IC Title:	MIECHV Program Model Eligibility Review Survey (State/Local Government)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	Model Eligibility Survey	Appendix C. Model Eligibility Review Survey.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 2	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 Agency Discretion
Annual Number of Responses for this IC	2	2
Annual IC Time Burden (Hours)	6	6
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.