ss 0915-0172 2008

SUPPORTING STATEMENT
MATERNAL AND CHILD HEALTH SERVICES BLOCK GRANT
APPLICATION GUIDANCE

1. CIRCUMSTANCES OF INFORMATION COLLECTION
This submission is a request for OMB approval of the revised guidance to be used by the 50
States and 9 jurisdictions eligible for State formula grants under the Maternal and Child Health
(MCH) Services Block Grant, authorized by Section 501 of Title V of the Social Security Act
(the Act), PL 101-239. The current guidance (OMB No. 0915-0172) has an expiration date of
May 31, 2009. The new guidance contains one combined document made up of instructions for
completing a needs assessment (conducted once every five years), an annual report, and an
application. The annual report fulfills the requirements of Section 506 and the application and
needs assessment fulfills the requirements of Section 505 of Title V. The attached guidance is
designed to allow States flexibility in meeting identified needs of women and children while
enabling the Maternal and Child Health Bureau (MCHB) to provide comparative data required
by Congress to account for the use of Federal funds. The MCHB, in the Health Resources and
Services Administration (HRSA), serves as the Secretary’s delegate to collect this information,
review it and use it to award approximately $600 million in State formula grants under the MCH
Block Grant program. This submission is a revision with no changes to the burden hours.
The revisions consist solely of instructions to the needs assessment process, and are nonsubstantive in nature. See the attachment labeled “changes to the block grant” for further
details.
The MCH Block Grant is a formula grant under which funds are awarded to all 59 States and
jurisdictions upon their submission of an acceptable plan to meet the health services needs of the
target populations of mothers, infants, children, and children with special health care needs.
Through this process, each State and jurisdiction must also provide and promote the development
and coordination of systems of care that are family-centered, community-based and culturally
appropriate.
History
The State health programs for mothers and children dates to 1935 when these programs were
first authorized under Title V of the original Social Security Act. In 1981, Title V was amended
to create a single block grant program, which consolidated seven related categorical health
services programs for mothers and children into the MCH Services Block Grant. Programs
folded into the block grant included: Maternal and Child Health and Children with Special
Needs Services; Supplemental Security Income for Children with Disabilities Program; LeadBased Poisoning Prevention; Genetic Disease; Sudden Infant Death Syndrome (SIDS);
Hemophilia Treatment Centers; and Adolescent Pregnancy Grants. In 1996, PL 104-193 created
a new section 510 of Title V establishing a separate program for abstinence education.
Beginning in 1982, eligible States and territories were required to submit annually to the
Secretary a Report of Intended Expenditures (RIE), which outlined the State’s general plans for
the use of block grant funds and an annual report, in an unspecified form and with unspecified

content, which would inform the Secretary about how block grant funds were spent. The
Omnibus Budget Reconciliation Act (OBRA) of 1989 tightened accountability under the MCH
Block Grant. Congress placed a 10 percent limit on administrative costs and mandated two
minimum spending requirements, at 30 percent: (1) for children’s preventive and primary health
services and (2) for services and service coordination for children with special health care needs.
Particular emphasis was placed on the provision of services for low-income individuals and the
development of comprehensive plans for State systems of services which would be responsive
both to the State’s 5 year needs assessment and resulting goals and objectives and consistent with
Healthy People 2000 objectives.
The new provisions of OBRA‘89 strengthened the requirements for annual State plans, changing
their designation from RIEs to standard applications. OBRA‘89 amendments to Title V
introduced very specific categories of services and reporting for States. The statutory language
regarding the standardized form and content of the MCH Block Grant application and annual
report was deemed sufficiently explicit by DHHS not to require further amplification through
regulations.
To meet the requirements of the 1993 Government Performance and Results Act (GPRA),
MCHB streamlined its guidance into a combined document inclusive of the annual report,
application and a five-year needs assessment. Previously, these were three separate documents
that were duplicative and onerous to the States. The attached Guidance still reflects the rights of
States to determine their own needs and programs and to be accountable for the progress needed
towards their stated goals under the block grant concept, while adhering to the specific statutory
requirements of Sections 501, 503-509 of the Act, and sound principles of public health practice
and maternal and child health services.
The guidance focuses on accountability and flexibility which is consistent with Title V
legislation and contributes to the goals of the Performance Partnerships initiative and GPRA.
These revisions were influenced by the Performance Partnership Grants (PPGs) developed under
the National Performance Review in 1995. These grants provide States more latitude in how
funds are used, in return for increased State and Federal accountability for achieving targeted
improvements in specific health status and performance measures.
Another influence on the revision of the guidelines, specifically on the development of
performance measures, continues to be the “MCH Pyramid,” which is a conceptual framework
for defining the core public health services delivered by MCH agencies (see attachment). From
bottom to top, the pyramid illustrates the basic types of services provided, in order of the size of
the population affected by the service. In developing the national performance and statenegotiated performance measures, consideration was given to whether all levels of the pyramid
were represented by the measures.
Proposed Changes
The proposed revisions build on the extensive modifications made to the guidance and forms in
2003 and 2006. (See attachments for the previous MCH Services Block Grant Guidance.) All of
the changes are a natural progression of the performance partnership concept. The proposed
revisions include:

2

1. The provision of more complete information on the Background and Conceptual
Framework for the Needs Assessment Process.
2. Clarification of what State grantees are expected to include in the five year Needs
Assessment Document.
3. Clarification of the information that States should include in the Annual Needs
Assessment Summary/Update, both in the year when the five year Needs Assessment is
conducted and in interim years.
4. Updates to Figure 2, the Needs Assessment diagram, to reflect all aspects of the Needs
Assessment process.
5. Clarification that States are to provide maternal and child health workforce information
as part of the capacity section.
6. Other minor changes and clarifications that enhance reporting instructions.
The MCHB and States continue to work in partnership to improve MCH data and to add to the
usefulness and completeness of the Block Grant application instructions. This collaborative
work included additions and revisions to the sections indicated below and updates to provide
more complete information on the background and conceptual framework for the Needs
Assessment Process.
Additions and revisions were made to section of the guidance that explains what State grantees
are expected to include in the Five Year Needs Assessment Document.
The section of the guidance that explains the information that State grantees should include in
the Annual Needs Assessment Summary/Update was revised. Revisions to this section better
explain the information to include in the Annual Needs Assessment Summary/Update, both in
the year when the five year Needs Assessment is conducted and in the interim years. Updates
were made to Figure 2, the Needs Assessment diagram, to include greater detail regarding the
steps that State grantees should follow in conducting the Five Year Needs Assessment.
Other minor changes and clarifications enhance the instructions for various parts of the guidance,
including the following:
•

PART TWO, Section III, Part B. Agency Capacity: The second paragraph clarifies that
States should discuss the system of services for both the MCH and CSHCN programs.

•

Standard Form (SF) 424: The requirement to print, sign, and mail in the Application
Face Sheet (SF 424) has been deleted. SF 424 is now submitted electronically along with
the rest of the application and annual report.

•

Tables 4a and 4b: The headings and instructions have been clarified to indicate that
States are to report information from the Annual Report year in these tables.

•

PART TWO, Section IV, Part E. Health Status Indicators (HSIs): Revisions to this
section clarify the type of information that States are to report annually for the HSIs.

3

•

PART TWO, Section IV, Part F. Other Program Activities: Revisions clarify the types of
information that States may want to include in this section.

•

Form 11, Performance Measure Tracking: Instructions clarify that States should provide
a footnote that identifies the data source for each measure.

The proposed revisions to the guidance will not change the annual burden to States and
jurisdictions incurred during the reporting process. Directions in the new guidance have been
expanded to enhance clarification. These changes were directly due to suggestions provided by
the States. The major topics which were enhanced relate to the Needs Assessment.
The existing electronic TVIS used by the States to submit their Block Grant Application and
Annual Report has been maintained and enhanced. Using the electronic system, the narrative
from the prior year's submission is available online in the system so that the applicant need only
edit those sections that have changed. This feature minimizes burden by avoiding duplicating
material. For NPM #2-6, the data obtained from the National Survey of Children with Special
Health Care Needs are pre-populated, which eliminates the need to retrieve and enter data from
this survey unless the states choose to use another data source. Also, notes from the prior year's
submission are available to the states, which allows for more efficient updating through edits
rather then recreating them. Data are entered once (in a data entry field on a given form), and
where those data are referenced elsewhere, the value is copied and displayed. The electronic
system includes an automatic character counter that tells the user how many characters the states
have left. Users do not need to independently track entries against the MCHB’s limits for each
section to ensure compliance. The electronic system includes forms status checker and data
alerts, which conduct automated checks on data validity, data consistency, and application
completeness, as well as value tolerance checks. This feature facilitates application review and
eliminates much of the previously required data cleaning activity. Also, the user may obtain an
immediate update at any point in time on the completeness and compliance of the application,
which reduces the need to conduct a review of the application. Data are saved directly to the
HRSA server so that no manual transmission is required. Finally, the automatic commitment of
data to the HRSA server eliminates the need for version control or data migration. Improved
efficiency by States in the completion of the application/annual report is reflected in data on the
mean number of sections completed by July 1, 2 weeks before the deadline of July 15. The mean
has increased every year for the last 3 years, from 12.24 in 2006, to 13.58 in 2007, and to 13.75
in 2008.
The data requested in the guidance are necessary to manage the system, monitor the status of
women and children and make States accountable for their funds. The continuation of annually
reported National and State performance measures; health status and health systems capacity
indicators, and more clear narrative instructions are examples of how the guidance has improved.
Elimination of redundancy will also reduce the burden on States. This reflects the public and
private sector movement towards performance-based models of “doing business” to demonstrate
value from investments.
In conclusion, the guidance ensures that the MCHB will be held accountable to demonstrate that
funds are being spent appropriately to improve the health of women and children.

4

2.

PURPOSE AND USE OF INFORMATION

The purpose of the Title V MCH Services Block Grant Program is to create Federal/State
partnerships in all 50 States and 9 jurisdictions to develop service systems to meet MCH
challenges which include the following:
•
•
•
•
•
•
•
•
•

Significantly reducing infant mortality.
Providing comprehensive care for women before, during, and after pregnancy and
childbirth.
Providing preventive and primary care services for infants, children, and adolescents.
Providing comprehensive care for children and adolescents with special health care
needs.
Immunizing all children.
Reducing adolescent pregnancy.
Putting into community practice national standards and guidelines for prenatal care, for
healthy and safe child care, and for the health supervision of infants, children, and
adolescents.
Assuring access to care for all mothers and children.
Meeting the nutritional and developmental needs of mothers, children, and families.

This Block Grant guidance builds upon the established performance partnership approach with
the State Title V agencies. It has been revised based on input provided by the State Title V
directors and State MCH epidemiologists in the MCH Block Grant Guidance Review Workgroup
meeting and the MCH Block Grant reviews. The proposed revisions to the Guidance are
intended to further improve and streamline the application submission process and to enhance
Federal and State efforts to identify priorities and implement strategies to meet the needs of the
MCH populations.
Uses of information
The data and attendant information that will be collected by the MCHB from the States through
the application/annual report, and the five year needs assessment offer utility to both HRSA,
MCHB, and to the individual States and jurisdictions.
Federal
The information collected from State Title V agencies in the application/annual report will be
used to comply with statutory requirements, including accountability, for MCH block grant
funds. MCHB will use the information to take two administrative actions:
• Acceptance of annual report submitted in accordance with standard format and requirements
of Section 506 of the Act; and
• Acceptance of a complete State application submitted in accordance with the standard format
and requirements of the Act.
Additionally, as mandated by Section 506, information provided through the annual report and
other sources of State data gathered by MCHB will be aggregated and analyzed for inclusion in
Title V Information System. The MCHB will use the data to set priorities and guide strategic
planning efforts.

5

State
States will use the data to aid in priority setting for their MCH populations; to respond to other
Federal, State, and local performance requirements/requests; and to develop and justify efforts to
advance MCH-related agendas with the legislatures and/or Governor’s offices.
Information Collection and Proposed Changes
The combined application/annual report will be completed and submitted to the MCHB on an
annual basis and the needs assessment will be conducted at least once every five years. These
data offer a consistent way for States to provide tabular information in order to facilitate
manipulation of data and production of reports. The annual report and application will reflect,
through the use of data forms and supporting narrative, a synthesis of the health status, problems,
services, funds, and performance that are planned and provided by Title V programs.
This guidance for data collection and reporting is consistent with GPRA and the Performance
Partnership Grant program initiatives because it allows MCHB and States to demonstrate
accountability for funds that are planned and provided by Title V programs. It is also consistent
with GPRA and the Performance Partnership Grant program initiatives because it allows MCHB
and States to demonstrate accountability for funds that are targeted toward improving the health
of women and children while working within the existing legislation. The following are the
main sections of the guidance that involve data collection and reporting: needs assessment;
national performance measures; State-negotiated performance measures; and health status and
health systems capacity indicators.
Needs Assessment
A comprehensive needs assessment, as required by Section 505 (a) (1) of the Act, will be
performed once every five years. Each State must set 5-year performance objective targets and
report annually on the progress (in the form of performance measures) for each of the national
core performance measures.
In addition, States are required to provide data on the health status and health systems capacity
indicators. This will help States determine the health status of their populations and to determine
future needs. State program activities that constitute their block grant effort will be described
and categorized by the four levels of the MCHB pyramid of services: direct health care,
enabling, population-based, and infrastructure building.
Performance Measures
Historically, adoption of new measures facilitates the State in expanding and enhancing their
data capacity.
National Performance Measures (NPM)
The NPM are a set of measures upon which each State and jurisdiction will report. Each
measure has six major components including goal, measure, definition, Healthy People
2010 objective, data source, and significance. These components are represented on a
detail sheet for each measure that summarized its characteristics. The Healthy People
2010 objective will be updated with comparable future updates as necessary. These

6

detail sheets assure consistent understanding and reporting among States, and when
appropriate, allow for national data aggregation. Footnotes containing additional
explanatory material can be added to the performance measures reporting form to
enhance understanding or highlight special conditions or concerns.
State Performance Measures (SPM)
Each State will develop and build on at least 7, but not more than 10, performance
measures. The State Performance Measures (SPM) will be reviewed by central MCHB
staff and discussed, with State staff during the annual report/application review session,
and approved in the notice of grant award letters from the MCHB. Each SPM will
require a completed detail sheet to document the previously mentioned NPM. In
addition, the State will discuss why each measure was chosen, its relationship to the
seven to ten priority needs, its level of placement in the pyramid, and its relationship with
the core national performance and outcome measures.
Health Systems Capacity Indicators and Health Status Indicators
This standard set of HSCI and HSI are different from performance measures in that they indicate
health status at one point in time and require no targets or program effort. Instead, these will
help a State or jurisdiction to determine its priority needs. They are crucial to the States in
conducting its needs assessment.
Health Systems Capacity Indicators
The HSCI are reported annually. These indicators are meant to be used as a selfassessment tool. Besides describing data sources and current findings, the State utilizes
these indicators to illustrate such things as:
• What has influenced the program’s ability to maintain and/or improve the HSCIs.
• What efforts are being made by the program in developing new strategies for
meeting the HSCIs.
• Any interpretation of what the data indicates.
• If a State Systems Development Initiative is in place, what is notable regarding it
and HSCI 9A (The ability of States to assure Maternal and Child Health (MCH)
program access to policy and program relevant information).
Health Status Indicators
The HSI are to be reported annually. Historically, the HSI were reported as such until the
previous guidance changed the reporting requirement to every five years with the needs
assessment. However, there is value to annual reporting and most of the State Title V
agencies have continued to report them on this basis. They contribute to the State’s
ability to:
• Provide information on the State’s residents;
• Assist in directing public health efforts;
• Serve as surveillance or monitoring tool; and
• Function as an evaluative measure.

7

3.

USE OF IMPROVED INFORMATION TECHNOLOGY

HRSA has made efforts to improve the use of information technology in data collection.
Following the approval of the 1997 revisions, HRSA developed and instituted an automated
electronic data collection process and implemented the Title V Information System (TVIS).
Electronic Data Reporting
The electronic data reporting has reduced the burden on States and jurisdictions because it
provides for automatic calculations or ratios, rates, and percentages, carries over data from year
to year, and assures that data used in multiple tables is entered only once. The web-based
application process will continue to reduce the data reporting burden of the States.
Title V Information System (TVIS)
TVIS is a database that allows users to search and sort data on the health status of the nation’s
mothers and children. This database assures that Title V program data on maternal and child
health are uniformly available from all 50 States and 9 jurisdictions. These data are entered from
the States’ annual Block Grant applications and reports. Access to the data enables States,
communities, policymakers, and health care professionals to make better-informed decisions
about meeting the health care needs of women and children in the United States. Since TVIS
makes all information publicly accessible on the web,1 this provides a strong incentive to the
States to ensure the quality and accuracy of the data submitted.
4.

EFFORTS TO IDENTIFY DUPLICATION

MCHB makes every effort not to duplicate data collection efforts of other Federal agencies, as
required by Section 509 (a) (5) of the Act. Most of the data requested in the guidance is unique
to the Title V program at the State and national level and is required by statute and needed by the
Department and not available elsewhere. The data requirements of Sections 505 and 506 have
been discussed extensively with the States in public meetings.
However, MCHB may be duplicating, in a minimal manner, some of the data submitted by States
to the Federal government (e.g. vital statistics) because States prefer to use more current
provisional data when setting priorities and planning, designing and measure programs rather
than older “final” data. “Final” data are older because of the time it takes from receipt of raw
data to cleaning and producing final data tables that are reported by the Centers for Disease
Control and Prevention. For example, when States are setting objectives, they will want to have
a current and comprehensive picture of their MCH health care scenario, and therefore, they may
report provisional data such as infant mortality rates, STD rates, and immunization rates.
A State needs assessment was submitted in FY2005 for FY 2006-2010. The combined annual
report and application document is submitted during the four intervening years and avoids
repetition of static areas because it only asks States to update significant changes in their
assessed needs.
1

Data reported annually by the States are available to the public at
https://perfdata.hrsa.gov/mchb/mchreports/Search/core/MeasureIndicatorMenu.asp.

8

5.

INVOLVEMENT OF SMALL ENTITIES

No small business or other small entities are involved.
6.

CONSEQUENCES OF INFORMATION COLLECTED LESS FREQUENTLY

Annual submission of this application and report is required by law to entitle a State to receive
block grant funds (Sec.505). An annual report on the expenditure of the previous year’s funds is
also required by Section 506 of Title V. Section 505(a) requires a State needs assessment every
5 years.
7.

CONSISTENCY WITH THE GUIDELINES IN 5 CFR 1320.5(d)(2)

This data collection is consistent with the guidelines in 5 CRF 1320.5(d)(2).
8.

CONSULTATION OUTSIDE THE AGENCY

The notice required in 5 CFR 1320.8(d) was published in the Federal Register, 73 FR 56596, on
September 29, 2008 (Vol. 73, No. 189, page 56596).
One comment was received, suggesting that information on the maternal and child health
workforce at the state and local levels, including full time equivalents, tenure of the workforce,
and projected changes in the workforce in the coming year, be collected as part of the capacity
section of the block grant narrative. In response to this comment, page 41 of the guidance has
been revised to encourage States to provide, in the capacity section of the block grant narrative,
MCH workforce information that may be available.
Collaborations and Partnerships Utilized in Developing the Proposed Revisions
There was an extensive collaboration process carried out for this Block Grant revision with the
involvement of a wide range of individuals and organizations. Included in this wide range were
a national professional organization and parent groups, as well as a Block Grant Guidance
Review Workgroup with representatives of the State MCH Directors, State Children with Special
Health Care Needs (CSHCN) Directors, and Family Voices representatives that convened in
May 2008. The attachments contain a list of the members of this Workgroup and a list of the
State Title V MCH and CSHCN Directors. Throughout this process, there was continuous
contact with the leadership and members of the Association of Maternal and Child Health
Programs (AMCHP), which includes State Title V Directors, other professionals interested in
public health programs, regional counselors, and individual State representatives. AMCHP’s
members are the primary users of the Guidance for the preparation of their State
Application/Annual Report. Most of the comments from the workgroup focused on how to
improve the Needs Assessment section of the guidance, in preparation for the five year Needs
Assessment that will be due in 2010. In July, a draft of the revised sections of the guidance was
circulated to the workgroup members for comment. Comments received from the workgroup

9

members have been incorporated into the attached version of the guidance. The timeline of this
collaboration and resulting changes to the draft Guidance follows.
May 21, 2008: MCH Block Grant Guidance Review Workgroup meeting.
July 2008: Informal, ad-hoc MCHB meetings to discuss proposed edits to Guidance
July 31, 2008: Email to MCH Block Grant Guidance Review Workgroup asking for comments
on draft Needs Assessment section of guidance.
August - September 2008: Received feedback from Block Grant Guidance Workgroup regarding
proposed revisions. Continued informal, ad-hoc MCHB meetings to finalize revision.
October 2008: Email sent to Block Grant Guidance Workgroup and all Title V MCH and
CSHCN Directors listing website for the 60 – day, Federal Register Notice and directions for
obtaining a final draft copy of the Guidance.
9.

REMUNERATION OF RESPONDENTS

Respondents will not be remunerated.
10.

ASSURANCE OF CONFIDENTIALITY

The Privacy Act does not apply in this data gathering effort because the information to be
collected will not identify any individuals by name or collect any individual information.
All annual reports and applications, and needs assessments and associated information submitted
under Title V are public documents and available to the public on demand. Section 505 requires
each State to have public disclosure for a period of time through the MCH Block Grant
application process to facilitate public review and comment by interested persons or
organizations during its development or transmittal.
11.

QUESTIONS OF A SENSITIVE NATURE

There are no questions of a sensitive nature associated with this data collection effort.
12.

ESTIMATES OF ANNUALIZED HOUR BURDEN

The burden estimate for this activity is based upon information provided by the pilot States as
well as previous experience by States in completing the report and application. In calendar year
2009, and 2011, States and jurisdictions will be submitting an application and annual report,
without a needs assessment, and in calendar year 2010, the States and jurisdictions will be
submitting an application and annual report with a needs assessment, for a total estimated
burden of 18,064 hours (or 306 hours per State or jurisdiction).
The estimated average annual burden is as follows:

10

Reporting Document

Number of
Respondents
59

Responses
per
Respondent
1

Application and Report
without Needs Assessment
(2009 & 2011)
Application with Needs
Assessment (2010)
Total Average Annual
Burden

59

1

59

Total
Responses
59

Burden
per
Response
270

Total
Burden
Hours
15,930

Cost
per
Hour
$30

Total
Hour
Cost
$477,900

59

378.5

22,332

$30

$669,960

59

306

18,064

$30

$541,920

The total estimate of annual burden is the average for the next three year period of Application submissions in which a Needs
Assessment will be required once. The Application submissions (with and without the Needs Assessment) are based on the
calendar year.

13.

ESTIMATES OF ANNUALIZED COST BURDEN TO RESPONDENTS

There is no capital, start-up costs, or operation and maintenance costs associated with this data
collection.
14.

ESTIMATES OF ANNUALIZED COST TO THE GOVERNMENT

Currently, two Federal staff full-time equivalents (FTEs) are directly associated with the
activities required by this project, with an average cost of $96,000 including salary and benefits.
In addition to directly salary and benefit costs, approximately $120,000 is needed for operational
costs relating to receiving, reviewing, accepting, and monitoring block grant applications and
annual reports (e.g. setting up and convening outside review panels and site visits, etc.) In
addition, about $500,000 in contract costs will be required annually for the operation of the
system for automated reporting and analysis of data (Title V Information System). On this basis,
the estimated annual cost to the Federal government is $812,000.
15.

CHANGES IN BURDEN

The current inventory for this activity is 18,064 hours and there is no change in the estimated
burden for this submission.
16.

TIME SCHEDULE, PUBLICATION AND ANALYSIS PLAN

The State MCH Block Grant annual report and application document is an annual data
collection. Every five years (beginning in 2000) the States will include a needs assessment.
Submission of all documents by States and jurisdictions will take place by July 15 of each year,
with review completed in early September. Announcements of funding decisions are usually
made by October, or as soon as possible in the fiscal year, after MCHB receives the
appropriation.
Aggregation of data from annual reports will begin each year in early fall after receipt of the
reports from States. It is estimated that data analysis and verification will take five to six months
to complete, allowing for ample contact with State personnel to verify data, make any
corrections, or resolve any other issues or questions.

11

17.

EXEMPTION FOR DISPLAY OF EXPIRATION DATE

The expiration date will be displayed.
18.

CERTIFICATIONS

This project meets all of the requirements in 5 CFR 1320.9. The certifications are included in
the package.

ATTACHMENTS
New MCH Services Title V Block Grant Guidance
MCH Pyramid
MCH Block Grant Guidance Review Workshop Committee Members
State Title V MCH and CSHCN Directors
Previous MCH Services Block Grant Guidance

12