View Information Collection Request (ICR) Package

Please note that the OMB number and expiration date may not have been determined when this Information Collection Request and associated Information Collection forms were submitted to OMB. The approved OMB number and expiration date may be found by clicking on the Notice of Action link below.

View ICR - OIRA Conclusion

OMB Control No: 0906-0042	ICR Reference No: 202102-0906-001
Status: Historical Active	Previous ICR Reference No: 201910-0906-004
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR: No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 02/08/2021
Retrieve Notice of Action (NOA)	Date Received in OIRA: 02/02/2021
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	04/30/2022	04/30/2022
Responses	7,303	0	5,955
Time Burden (Hours)	2,014	0	1,605
Cost Burden (Dollars)	0	0	0

ICR Summary of Burden

	Total Approved	Previously Approved	Change Due to Agency Discretion
Annual Number of Responses	7,303	5,955	1,348
Annual Time Burden (Hours)	2,014	1,605	409
Annual Cost Burden (Dollars)	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement: The instruments are survey screeners that the public will not see, therefore, no public burden statement or OMB #s/Exp. Dates are indicated on the documents. Burden increase is due to an increase in the sampling/respondent amounts, as per the Jan 2021 Non-Substantive Change Memo.

Annual Cost to Federal Government: $1,273,713

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination. No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination. No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Yes

Agency Contact: Elyana Bowman 301 443-3983 enadjem@hrsa.gov