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

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
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	Available
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

Information collection document groups

IC ID	Collection	Type	Status	Form
235104	MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified

ICR Details

OMB Control No: 0906-0042	ICR Reference No: 201910-0906-004
Status: Active	Previous ICR Reference No: 201902-0906-003
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 11/26/2019
	Date Received in OIRA: 10/29/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2022	04/30/2022	04/30/2022
Responses	5,955	0	5,955
Time Burden (Hours)	1,605	0	1,605
Cost Burden (Dollars)	0	0	0

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Abstract: 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.

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Authorizing Statute(s): US Code: 5 USC 5 CFR 1320.5(d)(2) Name of Law: Controlling Paperwork Burdens on the Public
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 57737	11/16/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 5455	02/21/2019
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	4, 6, 7, 11, 17a, 17b, 18a, 2, 3, 5, 8, 12, 14, 18b, 1, 9, 10, 13, 15, 16, 17c, 18c	01_Updated MCH Survey_AS_English.doc ,   02_Updated MCH Survey_FSM_English.doc ,   03_Updated MCH Survey_Guam_English.doc ,   04_Updated MCH Survey_RMI_English.doc ,   05_Updated MCH Survey_CNMI_English.doc ,   06_Updated MCH Survey_Palau_English.doc ,   07_Updated MCH Survey_PR_English.doc ,   08_Updated MCH Survey_USVI_English.doc ,   09_Updated MCH Survey_American Samoa_Samoan.doc ,   10_Updated MCH Survey_FSM_Chuukese.doc ,   11_Updated MCH Survey_Guam_Chuukese.doc ,   12_Updated MCH Survey_Guam_Tagalog.doc ,   13_Updated MCH Survey_Palau_Palauan.doc ,   14_Updated MCH Survey_Palau_Tagalog.doc ,   15_Updated MCH Survey_PR_Spanish.doc ,   16_Updated MCH Survey_USVI_Spanish.doc ,   17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx ,   17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx ,   17c_MCH Survey_RMI_Marshallese Aug 2019.doc ,   18a_MCH Jurisdictional Survey Eligibility and Cons ,   18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx ,   18c_MCH Survey_FSM_Pohnpeian.doc

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ICR Summary of Burden

table that charts list of burden

	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

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $1,273,713

Does this IC contain surveys, censuses, or employ statistical methods? No

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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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:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(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;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

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.

Certification Date: 10/29/2019

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