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 Modified
 
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 9 Yes Yes Fillable Fileable
Form and Instruction 10 Yes Yes Fillable Fileable
Form and Instruction 11 Yes Yes Fillable Fileable
Form and Instruction 12 Yes Yes Fillable Fileable
Form and Instruction 13 Yes Yes Fillable Fileable
Form and Instruction 14 Yes Yes Fillable Fileable
Form and Instruction 15 Yes Yes Fillable Fileable
Form and Instruction 16 Yes Yes Fillable Fileable
Form and Instruction 17c Yes Yes Fillable Fileable
Form and Instruction 18c Yes Yes Fillable Fileable

Health Public Health Monitoring

 

7,303 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 7,303 0 1,348 0 0 5,955
Annual IC Time Burden (Hours) 2,014 0 409 0 0 1,605
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
MCH Survey Eligibility and Consent Script_Marshallese 02/02/2021
MCH Survey Leave-Behind Consent_Marshallese 02/02/2021
MCH Survey Eligibility and Consent Script_Pohnpeian 02/02/2021
MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian 02/02/2021
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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