Information Collection

MCH Connects Survey

IC 231166 under ICR 201502-0915-002 · OMB 0915-0212.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0212 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 MCH Connects Survey	Form and Instruction
1 MCH Connects 3 Month Survey- FINAL.docx MCH Connects 3 Month Survey- FINAL.docx	Form and Instruction
+MCH-Connects_Supporting-Statements-FINAL.docx MCH Connect Generic SS	IC Document

IC Title:

MCH Connects Survey

Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	MCH Connects 3 Month Survey- FINAL.docx	MCH Connects 3 Month Survey- FINAL.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 53

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	53	53
Annual IC Time Burden (Hours)	5	5
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MCH Connect Generic SS	+MCH-Connects_Supporting-Statements-FINAL.docx	04/23/2018

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.