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View Information Collection (IC)

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
 
No New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.doc MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 2 MCH Survey_Adult Parents_US Virgin Islands_English Feb 2019.doc MCH Survey_Adult Parents_US Virgin Islands_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 3 MCH Survey_Adult Parents_Guam_English Feb 2019.doc MCH Survey_Adult Parents_Guam_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 4 MCH Survey_Adult Parents_American Samoa_English Feb 2019.doc MCH Survey_Adult Parents_American Samoa_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 5 MCH Survey_Adult Parents_Federated States of Micronesia_English Feb 2019.doc MCH Survey_Adult Parents_Federated States of Micronesia_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 6 MCH Survey_Adult Parents_Marshall Islands_English Feb 2019.doc MCH Survey_Adult Parents_Marshall Islands_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 7 MCH Survey_Adult Parents_No Mariana Islands_English Feb 2019.doc MCH Survey_Adult Parents_No Mariana Islands_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 8 MCH Survey_Adult Parents_Palau_English Feb 2019.doc MCH Survey_Adult Parents_Palau_English Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 1B MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 2B MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 3B MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 3C MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 4B MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019.doc MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 5B MCH Survey_Adult Parents_Fed States of Micronesia_Chuukese Feb 2019.doc MCH Survey_Adult Parents_Fed States of Micronesia_Chuukese Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 8B MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc Yes Yes Fillable Fileable
Form and Instruction 8C MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc Yes Yes Fillable Fileable

Health Public Health Monitoring

 

5,955 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 5,955 0 5,955 0 0 0
Annual IC Time Burden (Hours) 1,605 0 1,605 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
MCH Survey Eligibility and Consent Script_ENGLISH MCH Survey Eligibility and Consent Script_ENGLISH.docx 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx 02/26/2019
MCH Survey Leave-Behind Consent_ENGLISH MCH Survey Leave-Behind Consent_ENGLISH.docx 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx 02/26/2019
MCH Survey Eligibility and Consent Script_CHUUKESE MCH Survey Eligibility and Consent Script_CHUUKESE.docx 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_PALAUAN MCH Survey Eligibility and Consent Script_No Inc_PALAUAN.docx 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_TAGALOG MCH Survey Eligibility and Consent Script_No Inc_TAGALOG.docx 02/26/2019
MCH Survey Eligibility and Consent Script_SAMOAN MCH Survey Eligibility and Consent Script_SAMOAN.docx 02/26/2019
MCH Survey Eligibility and Consent Script_SPANISH MCH Survey Eligibility and Consent Script_SPANISH.docx 02/26/2019
MCH Survey Eligibility and Consent Script_TAGALOG MCH Survey Eligibility and Consent Script_TAGALOG.docx 02/26/2019
MCH Survey Leave-Behind Consent_CHUUKESE MCH Survey Leave-Behind Consent_CHUUKESE.docx 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_PALAUAN MCH Survey Leave-Behind Consent_No Incentive_PALAUAN.docx 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_TAGALOG MCH Survey Leave-Behind Consent_No Incentive_TAGALOG.docx 02/26/2019
MCH Survey Leave-Behind Consent_SAMOAN MCH Survey Leave-Behind Consent_SAMOAN.docx 02/26/2019
MCH Survey Leave-Behind Consent_SPANISH MCH Survey Leave-Behind Consent_SPANISH.docx 02/26/2019
MCH Survey Leave-Behind Consent_TAGALOG MCH Survey Leave-Behind Consent_TAGALOG.docx 02/26/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.