Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument

Questionnaire and Data Collection Testing, Evaluation, and Research for the Health Resources and Services Administration (HRSA)

OMB: 0915-0379

IC ID: 232178

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Information Collection (IC) Details

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Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form 3 2018 MCH Survey Juris Module_CNMI_English_Formatted.doc 2018 MCH Survey Juris Module_CNMI_English_Formatted.doc Yes No Printable Only
Form 4 2018 MCH Survey Juris Module_FSM_English_Formatted.doc 2018 MCH Survey Juris Module_FSM_English_Formatted.doc Yes No Printable Only
Form 5 2018 MCH Survey Juris Module_Guam_English_Formatted.doc 2018 MCH Survey Juris Module_Guam_English_Formatted.doc Yes No Printable Only
Form 6 2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc 2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc Yes No Printable Only
Form 7 2018 MCH Survey Juris Module_Palau_English_Formatted.doc 2018 MCH Survey Juris Module_Palau_English_Formatted.doc Yes No Printable Only
Form 8 2018 MCH Survey Juris Module_PR_English_Formatted.doc 2018 MCH Survey Juris Module_PR_English_Formatted.doc Yes No Printable Only
Form 9 2018 MCH Survey Juris Module_USVI_English_Formatted.doc 2018 MCH Survey Juris Module_USVI_English_Formatted.doc Yes No Printable Only
Form 10 2018 MCH Survey Core_AS_Samoan_Formatted.doc 2018 MCH Survey Core_AS_Samoan_Formatted.doc Yes No Printable Only
Form 11 2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc 2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc Yes No Printable Only
Form 12 2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc 2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc Yes No Printable Only
Form 13 2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc 2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc Yes No Printable Only
Form 14 2018 MCH Survey Core_Palau_Palauan_Formatted.doc 2018 MCH Survey Core_Palau_Palauan_Formatted.doc Yes No Printable Only
Form 15 2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx 2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx Yes No Printable Only
Form 16 2018 MCH Survey Core_Palau_Tagalog_Formatted.doc 2018 MCH Survey Core_Palau_Tagalog_Formatted.doc Yes No Printable Only
Form 17 2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx 2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx Yes No Printable Only
Form 18 2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc 2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc Yes No Printable Only
Form 19 2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx 2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx Yes No Printable Only
Form 20 2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx 2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx Yes No Printable Only
Form 1 2018 MCH Survey Core_English_Formatted FINAL.docx 2018 MCH Survey Core_English_Formatted FINAL.docx Yes No Printable Only
Form 2 2018 MCH Survey Juris Module_AS_English_Formatted.doc 2018 MCH Survey Juris Module_AS_English_Formatted.doc Yes No Printable Only

Health Public Health Monitoring

 

1,757 0
   
Individuals or Households
 
   0 %

  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 1,757 0 1,757 0 0 0
Annual IC Time Burden (Hours) 226 0 226 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Supporting Statement A FINAL FINAL Jurisdictional MCH Survey Supporting Statement A 7.12.18.docx 07/12/2018
Supporting Statement B FINAL Jurisdictional MCH Survey Supporting Statement B 7.12.18.docx 07/12/2018
Jurisdictional MCH Pretest Appendix A- Recruitment Flyer FINAL Jurisdictional MCH Pretest Appendix A- Recruitment Flyer FINAL.doc 07/12/2018
Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18 Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18.docx 07/12/2018
Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18 Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18.docx 07/12/2018
Jurisdictional MCH Pretest Appendix D- Written Consent 5.14.18 Jurisdictional MCH Pretest Appendix D- Written Consent 5.14.18.docx 07/12/2018
Jurisdictional MCH Pretest Appendix E- Written Consent NoInc 5.14.18 Jurisdictional MCH Pretest Appendix E- Written Consent NoInc 5.14.18.docx 07/12/2018
Appendix A1- Recruitment flyer-5.14.18 - Palauan Appendix A1- Recruitment flyer-5.14.18 - Palauan.doc 07/12/2018
Appendix A2- Recruitment flyer 5.14.18 - Marshallese Appendix A2- Recruitment flyer 5.14.18 - Marshallese.doc 07/12/2018
Appendix A3- Recruitment flyer 5.14.18 - Samoan Appendix A3- Recruitment flyer 5.14.18 - Samoan.doc 07/12/2018
Appendix A4- Recruitment flyer 5.14.18 - Spanish Appendix A4- Recruitment flyer 5.14.18 - Spanish.doc 07/12/2018
Appendix A5- Recruitment flyer 5.14.18 - Tagalog Appendix A5- Recruitment flyer 5.14.18 - Tagalog.doc 07/12/2018
Appendix B1- Script for Phone Mode 5.14.18 - Spanish Appendix B1- Script for Phone Mode 5.14.18 - Spanish.docx 07/12/2018
Appendix C1- Script for In Person Mode 5.14.18 - Palauan Appendix C1- Script for In Person Mode 5.14.18 - Palauan.docx 07/12/2018
Appendix C2- Script for In Person Mode 5.14.18 - Marshallese Appendix C2- Script for In Person Mode 5.14.18 - Marshallese.docx 07/12/2018
Appendix C3- Script for In Person Mode 5.14.18 - Samoan Appendix C3- Script for In Person Mode 5.14.18 - Samoan.docx 07/12/2018
Appendix C4- Script for In Person Mode 5.14.18 - Tagalog Appendix C4- Script for In Person Mode 5.14.18 - Tagalog.docx 07/12/2018
Appendix D1- Written Consent 5.14.18 - Samoan Appendix D1- Written Consent 5.14.18 - Samoan.docx 07/12/2018
Appendix E1- Written Consent NoInc 5.14.18 - Palauan Appendix E1- Written Consent NoInc 5.14.18 - Palauan.docx 07/12/2018
Appendix E2- Written Concent NoInc 5.14.18 - Marshallese Appendix E2- Written Concent NoInc 5.14.18 - Marshallese.docx 07/12/2018
Appendix E3- Written Consent NoInc 5.14.18 - Tagalog Appendix E3- Written Consent NoInc 5.14.18 - Tagalog.docx 07/12/2018
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