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 1a Yes Yes Fillable Fileable
Form and Instruction 1b Yes Yes Fillable Fileable
Form and Instruction 2a Yes Yes Fillable Fileable
Form and Instruction 3a Yes Yes Fillable Fileable
Form and Instruction 3b Yes Yes Fillable Fileable
Form and Instruction 3c Yes Yes Fillable Fileable
Form and Instruction 4a Yes Yes Fillable Fileable
Form and Instruction 4b Yes Yes Fillable Fileable
Form and Instruction 5a Yes Yes Fillable Fileable
Form and Instruction 5b Yes Yes Fillable Fileable
Form and Instruction 5c Yes Yes Fillable Fileable
Form and Instruction 6a Yes Yes Fillable Fileable
Form and Instruction 6b Yes Yes Fillable Fileable
Form and Instruction 7a Yes Yes Fillable Fileable
Form and Instruction 7b Yes Yes Fillable Fileable
Form and Instruction 8a Yes Yes Fillable Fileable
Form and Instruction 8b Yes Yes Fillable Fileable
Form and Instruction 4c 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 02/19/2025
eligibility consent script_ENGLISH 02/19/2025
eligibility consent script_ENGLISH_No Inc 02/19/2025
eligibility consent script_MARSHALLESE 02/19/2025
eligibility consent script_PALAUAN_No Inc 02/19/2025
eligibility consent script_POHNPEIAN 02/19/2025
eligibility consent script_SAMOAN 02/19/2025
eligibility consent script_SPANISH 02/19/2025
eligibility consent script_TAGALOG 02/19/2025
eligibility consent script_TAGALOG_No Inc 02/19/2025
leave-behind consent_CHUUKESE 02/19/2025
leave-behind consent_ENGLISH 02/19/2025
leave-behind consent_ENGLISH_No Inc 02/19/2025
leave-behind consent_MARSHALLESE 02/19/2025
leave-behind consent_PALAUAN 02/19/2025
leave-behind consent_POHNPEIAN 02/19/2025
leave-behind consent_SAMOAN 02/19/2025
leave-behind consent_SPANISH 02/19/2025
leave-behind consent_TAGALOG 02/19/2025
leave-behind consent_TAGALOG No Inc 02/19/2025
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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