Information Collection

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

IC 235104 under ICR 201902-0906-003 · OMB 0906-0042.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0906-0042 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
1 MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.do MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.doc	Form and Instruction
2 MCH Survey_Adult Parents_US Virgin Islands_English Feb 2 MCH Survey_Adult Parents_US Virgin Islands_English Feb 2019.doc	Form and Instruction
3 MCH Survey_Adult Parents_Guam_English Feb 2019.doc MCH Survey_Adult Parents_Guam_English Feb 2019.doc	Form and Instruction
4 MCH Survey_Adult Parents_American Samoa_English Feb 2019 MCH Survey_Adult Parents_American Samoa_English Feb 2019.doc	Form and Instruction
5 MCH Survey_Adult Parents_Federated States of Micronesia_ MCH Survey_Adult Parents_Federated States of Micronesia_English Feb 2019.doc	Form and Instruction
6 MCH Survey_Adult Parents_Marshall Islands_English Feb 20 MCH Survey_Adult Parents_Marshall Islands_English Feb 2019.doc	Form and Instruction
7 MCH Survey_Adult Parents_No Mariana Islands_English Feb MCH Survey_Adult Parents_No Mariana Islands_English Feb 2019.doc	Form and Instruction
8 MCH Survey_Adult Parents_Palau_English Feb 2019.doc MCH Survey_Adult Parents_Palau_English Feb 2019.doc	Form and Instruction
1B MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc	Form and Instruction
2B MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc	Form and Instruction
3B MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc	Form and Instruction
3C MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc	Form and Instruction
4B MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019. MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019.doc	Form and Instruction
5B MCH Survey_Adult Parents_Fed States of Micronesia_Chuuke MCH Survey_Adult Parents_Fed States of Micronesia_Chuukese Feb 2019.doc	Form and Instruction
8B MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc	Form and Instruction
8C MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc	Form and Instruction
MCH Survey Eligibility and Consent Script_ENGLISH.docx MCH Survey Eligibility and Consent Script_ENGLISH	IC Document
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx MCH Survey Eligibility and Consent Script_No Inc_ENGLISH	IC Document
MCH Survey Leave-Behind Consent_ENGLISH.docx MCH Survey Leave-Behind Consent_ENGLISH	IC Document
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx MCH Survey Leave-Behind Consent_No Incentive_ENGLISH	IC Document
MCH Survey Eligibility and Consent Script_CHUUKESE.docx MCH Survey Eligibility and Consent Script_CHUUKESE	IC Document
MCH Survey Eligibility and Consent Script_No Inc_PALAUAN.docx MCH Survey Eligibility and Consent Script_No Inc_PALAUAN	IC Document
MCH Survey Eligibility and Consent Script_No Inc_TAGALOG.docx MCH Survey Eligibility and Consent Script_No Inc_TAGALOG	IC Document
MCH Survey Eligibility and Consent Script_SAMOAN.docx MCH Survey Eligibility and Consent Script_SAMOAN	IC Document
MCH Survey Eligibility and Consent Script_SPANISH.docx MCH Survey Eligibility and Consent Script_SPANISH	IC Document
MCH Survey Eligibility and Consent Script_TAGALOG.docx MCH Survey Eligibility and Consent Script_TAGALOG	IC Document
MCH Survey Leave-Behind Consent_CHUUKESE.docx MCH Survey Leave-Behind Consent_CHUUKESE	IC Document
MCH Survey Leave-Behind Consent_No Incentive_PALAUAN.docx MCH Survey Leave-Behind Consent_No Incentive_PALAUAN	IC Document
MCH Survey Leave-Behind Consent_No Incentive_TAGALOG.docx MCH Survey Leave-Behind Consent_No Incentive_TAGALOG	IC Document
MCH Survey Leave-Behind Consent_SAMOAN.docx MCH Survey Leave-Behind Consent_SAMOAN	IC Document
MCH Survey Leave-Behind Consent_SPANISH.docx MCH Survey Leave-Behind Consent_SPANISH	IC Document
MCH Survey Leave-Behind Consent_TAGALOG.docx MCH Survey Leave-Behind Consent_TAGALOG	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.doc	MCH Survey_Adult Parents_Puerto Rico_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2	MCH Survey_Adult Parents_US Virgin Islands_English Feb 2019.doc	MCH Survey_Adult Parents_US Virgin Islands_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3	MCH Survey_Adult Parents_Guam_English Feb 2019.doc	MCH Survey_Adult Parents_Guam_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4	MCH Survey_Adult Parents_American Samoa_English Feb 2019.doc	MCH Survey_Adult Parents_American Samoa_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5	MCH Survey_Adult Parents_Federated States of Micronesia_English Feb 2019.doc	MCH Survey_Adult Parents_Federated States of Micronesia_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	6	MCH Survey_Adult Parents_Marshall Islands_English Feb 2019.doc	MCH Survey_Adult Parents_Marshall Islands_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	7	MCH Survey_Adult Parents_No Mariana Islands_English Feb 2019.doc	MCH Survey_Adult Parents_No Mariana Islands_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8	MCH Survey_Adult Parents_Palau_English Feb 2019.doc	MCH Survey_Adult Parents_Palau_English Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	1B	MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc	MCH Survey_Adult Parents_PR_Spanish Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	2B	MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc	MCH Survey_Adult Parents_USVI_Spanish Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3B	MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc	MCH Survey_Adult Parents_Guam_Tagalog Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	3C	MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc	MCH Survey_Adult Parents_Guam_Chuukese Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	4B	MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019.doc	MCH Survey_Adult Parents_American Samoa_Samoan Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	5B	MCH Survey_Adult Parents_Fed States of Micronesia_Chuukese Feb 2019.doc	MCH Survey_Adult Parents_Fed States of Micronesia_Chuukese Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8B	MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc	MCH Survey_Adult Parents_Palau_Palauan Feb 2019.doc	Yes	Yes	Fillable Fileable
Form and Instruction	8C	MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc	MCH Survey_Adult Parents_Palau_Tagalog Feb 2019.doc	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 5,955

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	5,955	5,955
Annual IC Time Burden (Hours)	1,605	1,605
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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