Information Collection

Application/Annual Report with Needs Assessment Summary

IC 6398 under ICR 201711-0915-001 · OMB 0915-0172.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0172 can be found here:

Documents and Forms

Document Name Document Type
Form 1 Application/Annual Report with Needs Assessment Summary Form and Instruction
1 Parts 1 & 2 Proposed Updated FY 2019_2021 MCH Block Gran Parts1and2 Proposed Updated FY 2019_2021 MCH Block Grant Guidance.Oct_18_2017.docx Form and Instruction
2 Part 3 Proposed Updated FY 2019_2021 MCH Block Grant Gui Part3Proposed Updated FY 2019_2021 MCH Block Grant Guidance Forms. Nov_7_2017.docx Form and Instruction
Proposed Updated Appendix_FY 2019_20121.MCH Block Grant Guidance.Oct_18_2017.pdf Proposed Updated Appendix_FY 2019_20121.MCH Block Grant Guidance IC Document
Proposed Updated FY 2019_2021 MCH Block Grant Guidance and Forms. Nov_7_2017.pdf Proposed Updated FY 2019_2021 MCH Block Grant Guidance and Forms IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Application/Annual Report with Needs Assessment Summary	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

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	Parts 1 & 2 Proposed Updated FY 2019_2021 MCH Block Grant Guidance	Parts1and2 Proposed Updated FY 2019_2021 MCH Block Grant Guidance.Oct_18_2017.docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Part 3 Proposed Updated FY 2019_2021 MCH Block Grant Guidance Forms	Part3Proposed Updated FY 2019_2021 MCH Block Grant Guidance Forms. Nov_7_2017.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 59	Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	59	0	59
Annual IC Time Burden (Hours)	8,437	-723	9,160
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Proposed Updated Appendix_FY 2019_20121.MCH Block Grant Guidance	Proposed Updated Appendix_FY 2019_20121.MCH Block Grant Guidance.Oct_18_2017.pdf	11/16/2017
Proposed Updated FY 2019_2021 MCH Block Grant Guidance and Forms	Proposed Updated FY 2019_2021 MCH Block Grant Guidance and Forms. Nov_7_2017.pdf	11/16/2017

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