Information Collection

Block Grant Application

IC 7545 under ICR 202201-0930-001 · OMB 0930-0168.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0930-0168 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form FFY 2022-2023 Bloc Block Grant Application	Form and Instruction
FFY 2022-2023 Bloc FFY 2022-2023 Block Grant Application FFY 2022-2023 Block Grant Application_ Clean 9.21.21_.docx	Form and Instruction
FFY 2022-2023 Bloc FFY 2022-2023 Block Grant Application FFY 2022-2023 Block Grant Application_ Clean 9.21.21_.docx	Form and Instruction
OMB MHBG Report _ Clean 9.21.21_.docx MHBG Report	IC Document
OMB MHBG Report _ Clean 9.21.21_.docx MHBG Report	IC Document
OMB SABG Report _ Clean 9.21.21_.docx SABG Report	IC Document
OMB SABG Report _ Clean 9.21.21_.docx SABG Report	IC Document

IC Title:

Block Grant Application

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	FFY 2022-2023 Block Grant Application	FFY 2022-2023 Block Grant Application	FFY 2022-2023 Block Grant Application_ Clean 9.21.21_.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 119

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	119	0	119
Annual IC Time Burden (Hours)	33,493	119	33,374
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
MHBG Report	OMB MHBG Report _ Clean 9.21.21_.docx	01/05/2022
SABG Report	OMB SABG Report _ Clean 9.21.21_.docx	01/05/2022

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