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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 201910-0906-004 · OMB 0906-0042 · Active

Forms and Documents
DocumentTypeStatusAvailability
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program Form and Instruction Modified Available
Jurisdictional Survey OMB Request for Non-Substantive ChangeLWS_OMB_9.24.2019_FINAL.docx Justification for No Material/Nonsubstantive Change Uploaded 2019-10-28 Available
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 Repair queued
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 Modified
ICR Details
0906-0042 201910-0906-004
Active 201902-0906-003
HHS/HRSA
Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
No material or nonsubstantive change to a currently approved collection   No
Regular
Approved without change 11/26/2019
Retrieve Notice of Action (NOA) 10/29/2019
  Inventory as of this Action Requested Previously Approved
04/30/2022 04/30/2022 04/30/2022
5,955 0 5,955
1,605 0 1,605
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 5,955 0 0 0 0
Annual Time Burden (Hours) 1,605 1,605 0 0 0 0
Annual Cost Burden (Dollars) 0 0 0 0 0 0
No
No
$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.
10/29/2019