View Information Collection (IC)
View Information Collection (IC)

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 Yes Yes Fillable Fileable
Form and Instruction 2 Yes Yes Fillable Fileable
Form and Instruction 3 Yes Yes Fillable Fileable
Form and Instruction 4 Yes Yes Fillable Fileable
Form and Instruction 5 Yes Yes Fillable Fileable
Form and Instruction 6 Yes Yes Fillable Fileable
Form and Instruction 7 Yes Yes Fillable Fileable
Form and Instruction 8 Yes Yes Fillable Fileable
Form and Instruction 1B Yes Yes Fillable Fileable
Form and Instruction 2B Yes Yes Fillable Fileable
Form and Instruction 3B Yes Yes Fillable Fileable
Form and Instruction 3C Yes Yes Fillable Fileable
Form and Instruction 4B Yes Yes Fillable Fileable
Form and Instruction 5B Yes Yes Fillable Fileable
Form and Instruction 8B Yes Yes Fillable Fileable
Form and Instruction 8C 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 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH 02/26/2019
MCH Survey Leave-Behind Consent_ENGLISH 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH 02/26/2019
MCH Survey Eligibility and Consent Script_CHUUKESE 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_PALAUAN 02/26/2019
MCH Survey Eligibility and Consent Script_No Inc_TAGALOG 02/26/2019
MCH Survey Eligibility and Consent Script_SAMOAN 02/26/2019
MCH Survey Eligibility and Consent Script_SPANISH 02/26/2019
MCH Survey Eligibility and Consent Script_TAGALOG 02/26/2019
MCH Survey Leave-Behind Consent_CHUUKESE 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_PALAUAN 02/26/2019
MCH Survey Leave-Behind Consent_No Incentive_TAGALOG 02/26/2019
MCH Survey Leave-Behind Consent_SAMOAN 02/26/2019
MCH Survey Leave-Behind Consent_SPANISH 02/26/2019
MCH Survey Leave-Behind Consent_TAGALOG 02/26/2019
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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