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 1 B Yes Yes Fillable Fileable
Form and Instruction 2 Yes Yes Fillable Fileable
Form and Instruction 2 B Yes Yes Fillable Fileable
Form and Instruction 3 Yes Yes Fillable Fileable
Form and Instruction 3 B Yes Yes Fillable Fileable
Form and Instruction 3 C Yes Yes Fillable Fileable
Form and Instruction 4 Yes Yes Fillable Fileable
Form and Instruction 4 B Yes Yes Fillable Fileable
Form and Instruction 5 Yes Yes Fillable Fileable
Form and Instruction 5 B Yes Yes Fillable Fileable
Form and Instruction 5 C Yes Yes Fillable Fileable
Form and Instruction 6 Yes Yes Fillable Fileable
Form and Instruction 6 B Yes Yes Fillable Fileable
Form and Instruction 7 Yes Yes Fillable Fileable
Form and Instruction 8 Yes Yes Fillable Fileable
Form and Instruction 8 B Yes Yes Fillable Fileable
Form and Instruction 8 C Yes Yes Fillable Fileable
Other-Survey Yes Yes Fillable Fileable
Other-Survey 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 0 0 0 7,303
Annual IC Time Burden (Hours) 2,002 0 0 0 0 2,002
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Eligibility and Consent Script English 03/09/2022
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx 03/09/2022
MCH Survey Leave-Behind Consent_ENGLISH.docx 03/09/2022
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx 03/09/2022
eligibility consent script_SPANISH 03/09/2022
leave-behind consent_SPANISH.DOCX 03/09/2022
eligibility consent script_CHUUKESE.docx 03/09/2022
leave-behind consent_CHUUKESE.docx 03/09/2022
eligibility consent script_TAGALOG.docx 03/09/2022
eligibility consent script_TAGALOG_No Inc.docx 03/09/2022
leave-behind consent_TAGALOG.docx 03/09/2022
leave-behind consent_TAGALOG_No Inc.docx 03/09/2022
eligibility consent script_SAMOAN.docx 03/09/2022
leave-behind consent_SAMOAN.docx 03/09/2022
eligibility consent script_POHNPEIAN.docx 03/09/2022
leave-behind consent_POHNPEIAN.docx 03/09/2022
eligibility consent script_MARSHALLESE.docx 03/09/2022
leave-behind consent_MARSHALLESE.docx 03/09/2022
eligibility consent script_PALAUAN_No Inc.docx 03/09/2022
leave-behind consent_PALAUAN.docx 03/09/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
Something went wrong when downloading this file. If you have any questions, please send an email to risc@gsa.gov.