Information Collection

Application/Annual Report with Needs Assessment Summary

IC 6398 under ICR 202011-0915-001 · OMB 0915-0172.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0172 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.