Information Collection

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

IC 235104 under ICR 202102-0906-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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 01_Updated MCH Survey_AS_English Jan 2021.docx 01_Updated MCH Survey_AS_English Jan 2021.docx	Form and Instruction
1 01_Updated MCH Survey_AS_English Jan 2021.docx 01_Updated MCH Survey_AS_English Jan 2021.docx	Form and Instruction
2 02_Updated MCH Survey_FSM_English Jan 2021.docx 02_Updated MCH Survey_FSM_English Jan 2021.docx	Form and Instruction
2 02_Updated MCH Survey_FSM_English Jan 2021.docx 02_Updated MCH Survey_FSM_English Jan 2021.docx	Form and Instruction
3 03_Updated MCH Survey_Guam_English Jan 2021.docx 03_Updated MCH Survey_Guam_English Jan 2021.docx	Form and Instruction
3 03_Updated MCH Survey_Guam_English Jan 2021.docx 03_Updated MCH Survey_Guam_English Jan 2021.docx	Form and Instruction
4 04_Updated MCH Survey_RMI_English Jan 2021.docx 04_Updated MCH Survey_RMI_English Jan 2021.docx	Form and Instruction
4 04_Updated MCH Survey_RMI_English Jan 2021.docx 04_Updated MCH Survey_RMI_English Jan 2021.docx	Form and Instruction
5 05_Updated MCH Survey_CNMI_English Jan 2021.docx 05_Updated MCH Survey_CNMI_English Jan 2021.docx	Form and Instruction
5 05_Updated MCH Survey_CNMI_English Jan 2021.docx 05_Updated MCH Survey_CNMI_English Jan 2021.docx	Form and Instruction
6 06_Updated MCH Survey_Palau_English Jan 2021.docx 06_Updated MCH Survey_Palau_English Jan 2021.docx	Form and Instruction
6 06_Updated MCH Survey_Palau_English Jan 2021.docx 06_Updated MCH Survey_Palau_English Jan 2021.docx	Form and Instruction
7 07_Updated MCH Survey_PR_English Jan 2021.docx 07_Updated MCH Survey_PR_English Jan 2021.docx	Form and Instruction
7 07_Updated MCH Survey_PR_English Jan 2021.docx 07_Updated MCH Survey_PR_English Jan 2021.docx	Form and Instruction
8 08_Updated MCH Survey_USVI_English Jan 2021.docx 08_Updated MCH Survey_USVI_English Jan 2021.docx	Form and Instruction
8 08_Updated MCH Survey_USVI_English Jan 2021.docx 08_Updated MCH Survey_USVI_English Jan 2021.docx	Form and Instruction
9 09_Updated MCH Survey_American Samoa_Samoan Jan 2021.doc 09_Updated MCH Survey_American Samoa_Samoan Jan 2021.docx	Form and Instruction
9 09_Updated MCH Survey_American Samoa_Samoan Jan 2021.doc 09_Updated MCH Survey_American Samoa_Samoan Jan 2021.docx	Form and Instruction
10 10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx 10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx	Form and Instruction
10 10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx 10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx	Form and Instruction
11 11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx 11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx	Form and Instruction
11 11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx 11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx	Form and Instruction
12 12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx 12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx	Form and Instruction
12 12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx 12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx	Form and Instruction
13 13_Updated MCH Survey_Palau_Palauan Jan 2021.docx 13_Updated MCH Survey_Palau_Palauan Jan 2021.docx	Form and Instruction
13 13_Updated MCH Survey_Palau_Palauan Jan 2021.docx 13_Updated MCH Survey_Palau_Palauan Jan 2021.docx	Form and Instruction
14 14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx 14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx	Form and Instruction
14 14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx 14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx	Form and Instruction
15 15_Updated MCH Survey_PR_Spanish Jan 2021.docx 15_Updated MCH Survey_PR_Spanish Jan 2021.docx	Form and Instruction
15 15_Updated MCH Survey_PR_Spanish Jan 2021.docx 15_Updated MCH Survey_PR_Spanish Jan 2021.docx	Form and Instruction
16 16_Updated MCH Survey_USVI_Spanish Jan 2021.docx 16_Updated MCH Survey_USVI_Spanish Jan 2021.docx	Form and Instruction
16 16_Updated MCH Survey_USVI_Spanish Jan 2021.docx 16_Updated MCH Survey_USVI_Spanish Jan 2021.docx	Form and Instruction
17c 17c_Updated MCH Survey_RMI_Marshallese Jan 2021.docx 17_Updated MCH Survey_RMI_Marshallese Jan 2021.docx	Form and Instruction
17c 17c_Updated MCH Survey_RMI_Marshallese Jan 2021.docx 17_Updated MCH Survey_RMI_Marshallese Jan 2021.docx	Form and Instruction
18c 18c_MCH Survey_FSM_Pohnpeian 18c_MCH Survey_FSM_Pohnpeian.docx	Form and Instruction
18c 18c_MCH Survey_FSM_Pohnpeian 18c_MCH Survey_FSM_Pohnpeian.docx	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_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 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_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 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_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_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_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_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_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 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_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_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_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_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_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
MCH Survey Leave-Behind Consent_TAGALOG.docx MCH Survey Leave-Behind Consent_TAGALOG	IC Document
17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx MCH Survey Eligibility and Consent Script_Marshallese	IC Document
17a_MCH Jurisdictional Survey Eligibility and Consent Script_Marshallese.docx MCH Survey Eligibility and Consent Script_Marshallese	IC Document
17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx MCH Survey Leave-Behind Consent_Marshallese	IC Document
17b_MCH Jurisdictional Survey Leave-Behind Consent_Marshallese.docx MCH Survey Leave-Behind Consent_Marshallese	IC Document
18a_MCH Jurisdictional Survey Eligibility and Consent Script_Pohnpeian.docx MCH Survey Eligibility and Consent Script_Pohnpeian	IC Document
18a_MCH Jurisdictional Survey Eligibility and Consent Script_Pohnpeian.docx MCH Survey Eligibility and Consent Script_Pohnpeian	IC Document
18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian	IC Document
18b_MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian.docx MCH Jurisdictional Survey Leave-Behind Consent_Pohnpeian	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: Modified

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	01_Updated MCH Survey_AS_English Jan 2021.docx	01_Updated MCH Survey_AS_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	02_Updated MCH Survey_FSM_English Jan 2021.docx	02_Updated MCH Survey_FSM_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	03_Updated MCH Survey_Guam_English Jan 2021.docx	03_Updated MCH Survey_Guam_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	04_Updated MCH Survey_RMI_English Jan 2021.docx	04_Updated MCH Survey_RMI_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	05_Updated MCH Survey_CNMI_English Jan 2021.docx	05_Updated MCH Survey_CNMI_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	06_Updated MCH Survey_Palau_English Jan 2021.docx	06_Updated MCH Survey_Palau_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7	07_Updated MCH Survey_PR_English Jan 2021.docx	07_Updated MCH Survey_PR_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8	08_Updated MCH Survey_USVI_English Jan 2021.docx	08_Updated MCH Survey_USVI_English Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	9	09_Updated MCH Survey_American Samoa_Samoan Jan 2021.docx	09_Updated MCH Survey_American Samoa_Samoan Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	10	10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx	10_Updated MCH Survey_FSM_Chuukese Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	11	11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx	11_Updated MCH Survey_Guam_Chuukese Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	12	12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx	12_Updated MCH Survey_Guam_Tagalog Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	13	13_Updated MCH Survey_Palau_Palauan Jan 2021.docx	13_Updated MCH Survey_Palau_Palauan Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	14	14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx	14_Updated MCH Survey_Palau_Tagalog Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	15	15_Updated MCH Survey_PR_Spanish Jan 2021.docx	15_Updated MCH Survey_PR_Spanish Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	16	16_Updated MCH Survey_USVI_Spanish Jan 2021.docx	16_Updated MCH Survey_USVI_Spanish Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	17c	17c_Updated MCH Survey_RMI_Marshallese Jan 2021.docx	17_Updated MCH Survey_RMI_Marshallese Jan 2021.docx	Yes	Yes	Fillable Fileable
Form and Instruction	18c	18c_MCH Survey_FSM_Pohnpeian	18c_MCH Survey_FSM_Pohnpeian.docx	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: 7,303

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	Previously Approved
Annual Number of Responses for this IC	7,303	1,348	5,955
Annual IC Time Burden (Hours)	2,014	409	1,605
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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