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Federal forms, ICRs, and supporting documents

Information Collection Request

Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

ICR 201902-0906-003 · OMB 0906-0042 · Historical Active

Forms and Documents
DocumentTypeStatusAvailability
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program Form and Instruction New Repair queued
MCH Jurisdictional Survey Crosswalk.docx Supplementary Document Uploaded 2019-04-11 Repair queued
MCH Jurisdictional Survey Supporting Statement B 2-15-19.docx Supporting Statement B Uploaded 2019-02-26 Available
MCH Jurisdictional Survey Supporting Statement A 4-10-2019.docx Supporting Statement A Uploaded 2019-04-10 Available
IC Document Collections
IC IDCollectionTypeStatusForm
235104 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program Form and Instruction New
ICR Details
0906-0042 201902-0906-003
Historical Active
HHS/HRSA
Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
New collection (Request for a new OMB Control Number)   No
Regular
Approved with change 04/16/2019
Retrieve Notice of Action (NOA) 02/27/2019
OMB is approving this information collection request for a period of three years during which time HRSA will request approval to extend or revise the collection if the agency seeks to continue the information collection activity beyond the period approved under this action.
  Inventory as of this Action Requested Previously Approved
04/30/2022 36 Months From Approved
5,955 0 0
1,605 0 0
0 0 0
HRSA/MCHB needs the Title V MCH Block Grant Jurisdictional MCH Survey to create a mechanism for jurisdictions to begin collecting, reporting and monitoring key MCH indicators over time. This data collection will enable the eight jurisdictions (i.e., American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin Islands) to meet Federal performance reporting requirements and to demonstrate the impact of Title V funding relative to MCH outcomes for the U.S. jurisdictions in reporting on their unique MCH priority needs. Having these data will allow for better annual reporting by the Federal program office in reporting to Congress on the jurisdictions’ Title V program accomplishments.
US Code: 5 USC 5 CFR 1320.5(d)(2) Name of Law: Controlling Paperwork Burdens on the Public
  
None
Not associated with rulemaking
  83 FR 57737 11/16/2018
84 FR 5455 02/21/2019
No
  Total Approved Previously Approved Change Due to New Statute Change Due to Agency Discretion Change Due to Adjustment in Estimate Change Due to Potential Violation of the PRA
Annual Number of Responses 5,955 0 0 5,955 0 0
Annual Time Burden (Hours) 1,605 0 0 1,605 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
Yes
Miscellaneous Actions
No
This is a new ICR, so increase is from zero (0).
$1,273,713
No
    No
    No
No
No
No
Uncollected
Elyana Bowman 301 443-3983 [email protected]
  No
On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).
The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:
 
 
 
 
 
 
 
    (i) Why the information is being collected;
    (ii) Use of information;
    (iii) Burden estimate;
    (iv) Nature of response (voluntary, required for a benefit, or mandatory);
    (v) Nature and extent of confidentiality; and
    (vi) Need to display currently valid OMB control number;
 
 
 
If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.
02/27/2019