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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 1a MCH-JS Survey_2024_American Samoa_English.docx MCH-JS Survey_2025_American Samoa_English.docx Yes Yes Fillable Fileable
Form and Instruction 1b MCH-JS Survey_2024_American Samoa_Samoan MCH-JS Survey_2025_American Samoa_Samoan.docx Yes Yes Fillable Fileable
Form and Instruction 2a MCH-JS Survey_2024_CNMI_English MCH-JS Survey_2025_CNMI_English.docx Yes Yes Fillable Fileable
Form and Instruction 3a MCH-JS Survey_2024_FSM_Chuukese MCH-JS Survey_2025_FSM_Chuukese.docx Yes Yes Fillable Fileable
Form and Instruction 3b MCH-JS Survey_2024_FSM_English MCH-JS Survey_2025_FSM_English.docx Yes Yes Fillable Fileable
Form and Instruction 3c MCH-JS Survey_2024_FSM_Pohnpeian MCH-JS Survey_2025_FSM_Pohnpeian.docx Yes Yes Fillable Fileable
Form and Instruction 4a MCH-JS Survey_2024_Guam_English MCH-JS Survey_2025_Guam_English.docx Yes Yes Fillable Fileable
Form and Instruction 4b MCH-JS Survey_2024_Guam_Tagalog MCH-JS Survey_2025_Guam_Tagalog.docx Yes Yes Fillable Fileable
Form and Instruction 5a MCH-JS Survey_2024_Palau_English MCH-JS Survey_2025_Palau_English.docx Yes Yes Fillable Fileable
Form and Instruction 5b MCH-JS Survey_2024_Palau_Palaun MCH-JS Survey_2025_Palau_Palaun.docx Yes Yes Fillable Fileable
Form and Instruction 5c MCH-JS Survey_2024_Palau_Tagalog MCH-JS Survey_2025_Palau_Tagalog.docx Yes Yes Fillable Fileable
Form and Instruction 6a MCH-JS Survey_2024_Puerto Rico_English MCH-JS Survey_2025_Puerto Rico_English.docx Yes Yes Fillable Fileable
Form and Instruction 6b MCH-JS Survey_2024_Puerto Rico_Spanish MCH-JS Survey_2025_Puerto Rico_Spanish.docx Yes Yes Fillable Fileable
Form and Instruction 7a MCH-JS Survey_2024_RMI_English MCH-JS Survey_2025_RMI_English.docx Yes Yes Fillable Fileable
Form and Instruction 7b MCH-JS Survey_2024_RMI_Marshallese MCH-JS Survey_2025_RMI_Marshallese.docx Yes Yes Fillable Fileable
Form and Instruction 8a MCH-JS Survey_2024_USVI_English MCH-JS Survey_2025_USVI_English.docx Yes Yes Fillable Fileable
Form and Instruction 8b MCH-JS Survey_2024_USVI_Spanish MCH-JS Survey_2025_USVI_Spanish.docx Yes Yes Fillable Fileable
Form and Instruction 4c MCH-JS Survey_2024_Guam_Chuukese MCH-JS Survey_2025_Guam_Chuukese.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

14,500 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 14,500 0 -3,084 0 0 17,584
Annual IC Time Burden (Hours) 3,155 0 -326 0 0 3,481
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
eligibility consent script_CHUUKESE eligibility consent script_CHUUKESE.docx 02/19/2025
eligibility consent script_ENGLISH eligibility consent script_ENGLISH.docx 02/19/2025
eligibility consent script_ENGLISH_No Inc eligibility consent script_ENGLISH_No Inc.docx 02/19/2025
eligibility consent script_MARSHALLESE eligibility consent script_MARSHALLESE.docx 02/19/2025
eligibility consent script_PALAUAN_No Inc eligibility consent script_PALAUAN_No Inc.docx 02/19/2025
eligibility consent script_POHNPEIAN eligibility consent script_POHNPEIAN.docx 02/19/2025
eligibility consent script_SAMOAN eligibility consent script_SAMOAN.docx 02/19/2025
eligibility consent script_SPANISH eligibility consent script_SPANISH.docx 02/19/2025
eligibility consent script_TAGALOG eligibility consent script_TAGALOG.docx 02/19/2025
eligibility consent script_TAGALOG_No Inc eligibility consent script_TAGALOG_No Inc.docx 02/19/2025
leave-behind consent_CHUUKESE MCH_JS_2025_leave-behind consent_CHUUKESE.docx 02/19/2025
leave-behind consent_ENGLISH MCH-JS_2025_leave-behind consent_ENGLISH.docx 02/19/2025
leave-behind consent_ENGLISH_No Inc MCH-JS_2025_leave-behind consent_ENGLISH_No Inc.docx 02/19/2025
leave-behind consent_MARSHALLESE MCH-JS_2025_leave-behind consent_MARSHALLESE.docx 02/19/2025
leave-behind consent_PALAUAN MCH-JS_2025_leave-behind consent_PALAUAN.docx 02/19/2025
leave-behind consent_POHNPEIAN MCH-JS_2025_leave-behind consent_POHNPEIAN.docx 02/19/2025
leave-behind consent_SAMOAN MCH-JS_2025_leave-behind consent_SAMOAN.docx 02/19/2025
leave-behind consent_SPANISH MCH-JS_2025_leave-behind consent_SPANISH.DOCX 02/19/2025
leave-behind consent_TAGALOG MCH-JS_2025_leave-behind consent_TAGALOG.docx 02/19/2025
leave-behind consent_TAGALOG No Inc MCH_JS_2025_leave-behind consent_TAGALOG_No Inc.docx 02/19/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.