Information Collection List

IC Title Status Responses Hours Dollars Document Type Form No. Form Name
Pre-testing for 2019 Health Center Patient Survey (HCPS) New 88 77 0 Form and Instruction 1E Attachment 1E Patient Screening (English).docx
Form and Instruction 1S Attachment 1S Patient Screening (Spanish).docx
Form and Instruction 2E Attachment 2E Patient Screening Short Blessed Scale (English).docx
Form and Instruction 2S Attachment 2S Patient Screening Short Blessed Scale (Spanish).DOC
Form and Instruction 2V Attachment 2V Patient Screening Short Blessed Scale (Vietnamese).DOCX
Form and Instruction 2C Attachment 2C Patient Screening Short Blessed Scale (Chinese).DOCX
Form and Instruction 2T Attachment 2T Patient Screening Short Blessed Scale (Tagalog).DOCX
Form and Instruction 3E Attachment 3E Patient Survey (English) 06.21.19.docx
Form and Instruction 3S Attachment 3S Patient Survey (Spanish) 06.21.19.docx
Form and Instruction 3V Attachment 3V Patient Survey (Vietnamese) 06.21.19.docx
Form and Instruction 3C Attachment 3C Patient Survey (Chinese) 06.21.19.docx
Form and Instruction 3T Attachment 3T Patient Survey (Tagalog) 06.21.19.docx
Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument New 1757 226 0 Form 1 2018 MCH Survey Core_English_Formatted FINAL.docx
Form 2 2018 MCH Survey Juris Module_AS_English_Formatted.doc
Form 3 2018 MCH Survey Juris Module_CNMI_English_Formatted.doc
Form 4 2018 MCH Survey Juris Module_FSM_English_Formatted.doc
Form 5 2018 MCH Survey Juris Module_Guam_English_Formatted.doc
Form 6 2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc
Form 7 2018 MCH Survey Juris Module_Palau_English_Formatted.doc
Form 8 2018 MCH Survey Juris Module_PR_English_Formatted.doc
Form 9 2018 MCH Survey Juris Module_USVI_English_Formatted.doc
Form 10 2018 MCH Survey Core_AS_Samoan_Formatted.doc
Form 11 2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc
Form 12 2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc
Form 13 2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc
Form 14 2018 MCH Survey Core_Palau_Palauan_Formatted.doc
Form 15 2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx
Form 16 2018 MCH Survey Core_Palau_Tagalog_Formatted.doc
Form 17 2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx
Form 18 2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc
Form 19 2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx
Form 20 2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx
Total Burden Actually Used for Information Collections Under Currently Approved ICR: 1845 303 0  
Total Burden Currently Requested for Information Collections Under Currently Approved ICR: 0 0 0  
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