Information Collection

Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service

IC 221921 under ICR 202201-0970-011 · OMB 0970-0389.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0970-0389 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service Form and Instruction
1 Demographic and Service Utilization Data and Service Tribal MIECHV Form 1 CLEAN.docx Form and Instruction
1 Demographic and Service Utilization Data and Service Tribal MIECHV Form 1 CLEAN.docx Form and Instruction

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Tribal MIECHV Form 1: Demographic and Service Utilization Data and Service	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 and Service Utilization Data and Service	Tribal MIECHV Form 1 CLEAN.docx		Yes	Yes	Fillable Fileable

Line of Business: Community and Social Services

Subfunction: Social Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 23	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	Previously Approved
Annual Number of Responses for this IC	23	-2	25
Annual IC Time Burden (Hours)	11,500	-1,000	12,500
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.