MCH Connects Survey

Voluntary Partner Surveys to Implement Executive Order 12862 in the Health Resources and Services Administration

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

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

Information Collection (IC) Details

IC Title:	MCH Connects Survey	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection 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 %

	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

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.