Information Collection List

IC Title	Status	Responses	Hours	Dollars	Document Type	Form No.	Form Name
MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Modified	17584	3481	0	Form and Instruction	1	questionnaire PR english.docx
					Form and Instruction	1 B	questionnaire PR spanish.docx
					Form and Instruction	2	questionnaire USVI english.docx
					Form and Instruction	2 B	questionnaire USVI spanish.docx
					Form and Instruction	3	questionnaire Guam english.docx
					Form and Instruction	3 B	questionnaire Guam chuukese.docx
					Form and Instruction	3 C	questionnaire Guam tagalog.docx
					Form and Instruction	4	questionnaire AS english.docx
					Form and Instruction	4 B	questionnaire AS samoan.docx
					Form and Instruction	5	questionnaire FSM english.docx
					Form and Instruction	5 B	questionnaire FSM chuukese.docx
					Form and Instruction	5 C	questionnaire FSM pohnpeian.docx
					Form and Instruction	6	questionnaire RMI english.docx
					Form and Instruction	6 B	questionnaire RMI marshallese.docx
					Form and Instruction	7	questionnaire CNMI english.docx
					Form and Instruction	8	questionnaire Palau english.docx
					Form and Instruction	8 B	questionnaire Palau palauan.docx
					Form and Instruction	8 C	questionnaire Palau tagalog.docx
					Other-Survey
					Other-Survey
Total burden requested under this ICR:		17584	3481	0
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