Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.
MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Modified	7303	2002	0	Form and Instruction	1
					Form and Instruction	1 B
					Form and Instruction	2
					Form and Instruction	2 B
					Form and Instruction	3
					Form and Instruction	3 B
					Form and Instruction	3 C
					Form and Instruction	4
					Form and Instruction	4 B
					Form and Instruction	5
					Form and Instruction	5 B
					Form and Instruction	5 C
					Form and Instruction	6
					Form and Instruction	6 B
					Form and Instruction	7
					Form and Instruction	8
					Form and Instruction	8 B
					Form and Instruction	8 C
Total burden requested under this ICR:		7303	2002	0
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