Information Collection

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

IC 232178 under ICR 201704-0915-001 · OMB 0915-0379.

Documents and Forms

Documents and forms in this information collection
Document NameDocument Type
Form 1
2018 MCH Survey Core_English_Formatted FINAL.docx Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 2
2018 MCH Survey Juris Module_AS_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 3
2018 MCH Survey Juris Module_CNMI_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 4
2018 MCH Survey Juris Module_FSM_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 5
2018 MCH Survey Juris Module_Guam_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 6
2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 7
2018 MCH Survey Juris Module_Palau_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 8
2018 MCH Survey Juris Module_PR_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 9
2018 MCH Survey Juris Module_USVI_English_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 10
2018 MCH Survey Core_AS_Samoan_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 11
2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 12
2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 13
2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 14
2018 MCH Survey Core_Palau_Palauan_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 15
2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 16
2018 MCH Survey Core_Palau_Tagalog_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 17
2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 18
2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 19
2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
Form 20
2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx Title V Maternal and Child Health (MCH) Block Grant Jurisdictional MCH Survey Instrument
Form
1 2018 MCH Survey Core_English_Formatted FINAL.docx
2018 MCH Survey Core_English_Formatted FINAL.docx
Form
2 2018 MCH Survey Juris Module_AS_English_Formatted.doc
2018 MCH Survey Juris Module_AS_English_Formatted.doc
Form
3 2018 MCH Survey Juris Module_CNMI_English_Formatted.doc
2018 MCH Survey Juris Module_CNMI_English_Formatted.doc
Form
4 2018 MCH Survey Juris Module_FSM_English_Formatted.doc
2018 MCH Survey Juris Module_FSM_English_Formatted.doc
Form
5 2018 MCH Survey Juris Module_Guam_English_Formatted.doc
2018 MCH Survey Juris Module_Guam_English_Formatted.doc
Form
6 2018 MCH Survey Juris Module_MarshallIslands_English_For
2018 MCH Survey Juris Module_MarshallIslands_English_Formatted.doc
Form
7 2018 MCH Survey Juris Module_Palau_English_Formatted.doc
2018 MCH Survey Juris Module_Palau_English_Formatted.doc
Form
8 2018 MCH Survey Juris Module_PR_English_Formatted.doc
2018 MCH Survey Juris Module_PR_English_Formatted.doc
Form
9 2018 MCH Survey Juris Module_USVI_English_Formatted.doc
2018 MCH Survey Juris Module_USVI_English_Formatted.doc
Form
10 2018 MCH Survey Core_AS_Samoan_Formatted.doc
2018 MCH Survey Core_AS_Samoan_Formatted.doc
Form
11 2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc
2018 MCH Survey Juris Module_AS_Samoan_Formatted.doc
Form
12 2018 MCH Survey Core_MarshallIslands_Marshallese_Formatt
2018 MCH Survey Core_MarshallIslands_Marshallese_Formatted.doc
Form
13 2018 MCH Survey Juris Module_MarshallIslands_Marshallese
2018 MCH Survey Juris Module_MarshallIslands_Marshallese_Formatted.doc
Form
14 2018 MCH Survey Core_Palau_Palauan_Formatted.doc
2018 MCH Survey Core_Palau_Palauan_Formatted.doc
Form
15 2018 MCH Survey Juris Module_Palau_Palauan_Formatted.doc
2018 MCH Survey Juris Module_Palau_Palauan_Formatted.docx
Form
16 2018 MCH Survey Core_Palau_Tagalog_Formatted.doc
2018 MCH Survey Core_Palau_Tagalog_Formatted.doc
Form
17 2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.doc
2018 MCH Survey Juris Module_Palau_Tagalog_Formatted.docx
Form
18 2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc
2018 MCH Survey Core_USVIandPR_Spanish_Formatted.doc
Form
19 2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx
2018 MCH Survey Juris Module_PR_Spanish_Formatted.docx
Form
20 2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx
2018 MCH Survey Juris Module_USVI_Spanish_Formatted.docx
Form
FINAL Jurisdictional MCH Survey Supporting Statement A 7.12.18.docx
Supporting Statement A FINAL
IC Document
FINAL Jurisdictional MCH Survey Supporting Statement B 7.12.18.docx
Supporting Statement B
IC Document
Jurisdictional MCH Pretest Appendix A- Recruitment Flyer FINAL.doc
Jurisdictional MCH Pretest Appendix A- Recruitment Flyer FINAL
IC Document
Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18.docx
Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18
IC Document
Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18.docx
Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18
IC Document
Jurisdictional MCH Pretest Appendix D- Written Consent 5.14.18.docx
Jurisdictional MCH Pretest Appendix D- Written Consent 5.14.18
IC Document
Jurisdictional MCH Pretest Appendix E- Written Consent NoInc 5.14.18.docx
Jurisdictional MCH Pretest Appendix E- Written Consent NoInc 5.14.18
IC Document
Appendix A1- Recruitment flyer-5.14.18 - Palauan.doc
Appendix A1- Recruitment flyer-5.14.18 - Palauan
IC Document
Appendix A2- Recruitment flyer 5.14.18 - Marshallese.doc
Appendix A2- Recruitment flyer 5.14.18 - Marshallese
IC Document
Appendix A3- Recruitment flyer 5.14.18 - Samoan.doc
Appendix A3- Recruitment flyer 5.14.18 - Samoan
IC Document
Appendix A4- Recruitment flyer 5.14.18 - Spanish.doc
Appendix A4- Recruitment flyer 5.14.18 - Spanish
IC Document
Appendix A5- Recruitment flyer 5.14.18 - Tagalog.doc
Appendix A5- Recruitment flyer 5.14.18 - Tagalog
IC Document
Appendix B1- Script for Phone Mode 5.14.18 - Spanish.docx
Appendix B1- Script for Phone Mode 5.14.18 - Spanish
IC Document
Appendix C1- Script for In Person Mode 5.14.18 - Palauan.docx
Appendix C1- Script for In Person Mode 5.14.18 - Palauan
IC Document
Appendix C2- Script for In Person Mode 5.14.18 - Marshallese.docx
Appendix C2- Script for In Person Mode 5.14.18 - Marshallese
IC Document
Appendix C3- Script for In Person Mode 5.14.18 - Samoan.docx
Appendix C3- Script for In Person Mode 5.14.18 - Samoan
IC Document
Appendix C4- Script for In Person Mode 5.14.18 - Tagalog.docx
Appendix C4- Script for In Person Mode 5.14.18 - Tagalog
IC Document
Appendix D1- Written Consent 5.14.18 - Samoan.docx
Appendix D1- Written Consent 5.14.18 - Samoan
IC Document
Appendix E1- Written Consent NoInc 5.14.18 - Palauan.docx
Appendix E1- Written Consent NoInc 5.14.18 - Palauan
IC Document
Appendix E2- Written Concent NoInc 5.14.18 - Marshallese.docx
Appendix E2- Written Concent NoInc 5.14.18 - Marshallese
IC Document
Appendix E3- Written Consent NoInc 5.14.18 - Tagalog.docx
Appendix E3- Written Consent NoInc 5.14.18 - Tagalog
IC Document

Information Collection (IC) Details

View Information Collection (IC)

layout table

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 1 Yes No Printable Only
Form 2 Yes No Printable Only
Form 3 Yes No Printable Only
Form 4 Yes No Printable Only
Form 5 Yes No Printable Only
Form 6 Yes No Printable Only
Form 7 Yes No Printable Only
Form 8 Yes No Printable Only
Form 9 Yes No Printable Only
Form 10 Yes No Printable Only
Form 11 Yes No Printable Only
Form 12 Yes No Printable Only
Form 13 Yes No Printable Only
Form 14 Yes No Printable Only
Form 15 Yes No Printable Only
Form 16 Yes No Printable Only
Form 17 Yes No Printable Only
Form 18 Yes No Printable Only
Form 19 Yes No Printable Only
Form 20 Yes No Printable Only

Federal Enterprise Architecture Business Reference Module


table that charts list of burden
  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

Documents for IC
table that charts IC Documents
Title Document Date Uploaded
Supporting Statement A FINAL 07/12/2018
Supporting Statement B 07/12/2018
Jurisdictional MCH Pretest Appendix A- Recruitment Flyer FINAL 07/12/2018
Jurisdictional MCH Pretest Appendix B- Script for Phone Mode 7.9.18 07/12/2018
Jurisdictional MCH Pretest Appendix C- Script for In Person Mode 7.9.18 07/12/2018
Jurisdictional MCH Pretest Appendix D- Written Consent 5.14.18 07/12/2018
Jurisdictional MCH Pretest Appendix E- Written Consent NoInc 5.14.18 07/12/2018
Appendix A1- Recruitment flyer-5.14.18 - Palauan 07/12/2018
Appendix A2- Recruitment flyer 5.14.18 - Marshallese 07/12/2018
Appendix A3- Recruitment flyer 5.14.18 - Samoan 07/12/2018
Appendix A4- Recruitment flyer 5.14.18 - Spanish 07/12/2018
Appendix A5- Recruitment flyer 5.14.18 - Tagalog 07/12/2018
Appendix B1- Script for Phone Mode 5.14.18 - Spanish 07/12/2018
Appendix C1- Script for In Person Mode 5.14.18 - Palauan 07/12/2018
Appendix C2- Script for In Person Mode 5.14.18 - Marshallese 07/12/2018
Appendix C3- Script for In Person Mode 5.14.18 - Samoan 07/12/2018
Appendix C4- Script for In Person Mode 5.14.18 - Tagalog 07/12/2018
Appendix D1- Written Consent 5.14.18 - Samoan 07/12/2018
Appendix E1- Written Consent NoInc 5.14.18 - Palauan 07/12/2018
Appendix E2- Written Concent NoInc 5.14.18 - Marshallese 07/12/2018
Appendix E3- Written Consent NoInc 5.14.18 - Tagalog 07/12/2018
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.
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