Application/Annual Report with Needs Assessment Summary

Maternal and Child Health Services Block Grant Application/Annual Report Guidance

⚠️ Notice: This information collection may be referencing outdated material.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 Attachment A FORM - MCH Block Grant Guidance_October_26_ Attachment A FORM - MCH Block Grant Guidance_October_26_2020-FINAL.docx Form and Instruction
1 Attachment A FORM - MCH Block Grant Guidance_October_26_ Attachment A FORM - MCH Block Grant Guidance_October_26_2020-FINAL.docx Form and Instruction
Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL.docx Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL IC Document
Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL.docx Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL IC Document

Information Collection (IC) Details

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	Attachment A FORM - MCH Block Grant Guidance_October_26_2020-FINAL.docx	Attachment A FORM - MCH Block Grant Guidance_October_26_2020-FINAL.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)	7,080	-1,357	8,437
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

Title	Document	Date Uploaded
Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL	Narrative Instructions_ MCH Block Grant Guidance _10_26_2020-FINAL.docx	11/15/2020

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