Information Collection

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

IC 235104 under ICR 202203-0906-002 · 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⚠️ Notice: This information collection may be referencing outdated material.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 questionnaire PR english.docx questionnaire PR english.docx	Form and Instruction
1 questionnaire PR english.docx questionnaire PR english.docx	Form and Instruction
1 B questionnaire PR spanish.docx questionnaire PR spanish.docx	Form and Instruction
1 B questionnaire PR spanish.docx questionnaire PR spanish.docx	Form and Instruction
2 questionnaire USVI english.docx questionnaire USVI english.docx	Form and Instruction
2 questionnaire USVI english.docx questionnaire USVI english.docx	Form and Instruction
2 B questionnaire USVI spanish.docx questionnaire USVI spanish.docx	Form and Instruction
2 B questionnaire USVI spanish.docx questionnaire USVI spanish.docx	Form and Instruction
3 questionnaire Guam english.docx questionnaire Guam english.docx	Form and Instruction
3 questionnaire Guam english.docx questionnaire Guam english.docx	Form and Instruction
3 B questionnaire Guam chuukese.docx questionnaire Guam chuukese.docx	Form and Instruction
3 B questionnaire Guam chuukese.docx questionnaire Guam chuukese.docx	Form and Instruction
3 C questionnaire Guam tagalog.docx questionnaire Guam tagalog.docx	Form and Instruction
3 C questionnaire Guam tagalog.docx questionnaire Guam tagalog.docx	Form and Instruction
4 questionnaire AS english.docx questionnaire AS english.docx	Form and Instruction
4 questionnaire AS english.docx questionnaire AS english.docx	Form and Instruction
4 B questionnaire AS samoan.docx questionnaire AS samoan.docx	Form and Instruction
4 B questionnaire AS samoan.docx questionnaire AS samoan.docx	Form and Instruction
5 questionnaire FSM english.docx questionnaire FSM english.docx	Form and Instruction
5 questionnaire FSM english.docx questionnaire FSM english.docx	Form and Instruction
5 B questionnaire FSM chuukese.docx questionnaire FSM chuukese.docx	Form and Instruction
5 B questionnaire FSM chuukese.docx questionnaire FSM chuukese.docx	Form and Instruction
5 C questionnaire FSM pohnpeian.docx questionnaire FSM pohnpeian.docx	Form and Instruction
5 C questionnaire FSM pohnpeian.docx questionnaire FSM pohnpeian.docx	Form and Instruction
6 questionnaire RMI english.docx questionnaire RMI english.docx	Form and Instruction
6 questionnaire RMI english.docx questionnaire RMI english.docx	Form and Instruction
6 B questionnaire RMI marshallese.docx questionnaire RMI marshallese.docx	Form and Instruction
6 B questionnaire RMI marshallese.docx questionnaire RMI marshallese.docx	Form and Instruction
7 questionnaire CNMI english.docx questionnaire CNMI english.docx	Form and Instruction
7 questionnaire CNMI english.docx questionnaire CNMI english.docx	Form and Instruction
8 questionnaire Palau english.docx questionnaire Palau english.docx	Form and Instruction
8 questionnaire Palau english.docx questionnaire Palau english.docx	Form and Instruction
8 B questionnaire Palau palauan.docx questionnaire Palau palauan.docx	Form and Instruction
8 B questionnaire Palau palauan.docx questionnaire Palau palauan.docx	Form and Instruction
8 C questionnaire Palau tagalog.docx questionnaire Palau tagalog.docx	Form and Instruction
8 C questionnaire Palau tagalog.docx questionnaire Palau tagalog.docx	Form and Instruction
MCH Survey Eligibility and Consent Script_ENGLISH.docx Eligibility and Consent Script English	IC Document
MCH Survey Eligibility and Consent Script_ENGLISH.docx 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.docx	IC Document
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx	IC Document
MCH Survey Leave-Behind Consent_ENGLISH.docx MCH Survey Leave-Behind Consent_ENGLISH.docx	IC Document
MCH Survey Leave-Behind Consent_ENGLISH.docx MCH Survey Leave-Behind Consent_ENGLISH.docx	IC Document
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx	IC Document
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx	IC Document
eligibility consent script_SPANISH.docx eligibility consent script_SPANISH	IC Document
eligibility consent script_SPANISH.docx eligibility consent script_SPANISH	IC Document
leave-behind consent_SPANISH.DOCX leave-behind consent_SPANISH.DOCX	IC Document
leave-behind consent_SPANISH.DOCX leave-behind consent_SPANISH.DOCX	IC Document
eligibility consent script_CHUUKESE.docx eligibility consent script_CHUUKESE.docx	IC Document
eligibility consent script_CHUUKESE.docx eligibility consent script_CHUUKESE.docx	IC Document
leave-behind consent_CHUUKESE.docx leave-behind consent_CHUUKESE.docx	IC Document
leave-behind consent_CHUUKESE.docx leave-behind consent_CHUUKESE.docx	IC Document
eligibility consent script_TAGALOG.docx eligibility consent script_TAGALOG.docx	IC Document
eligibility consent script_TAGALOG.docx eligibility consent script_TAGALOG.docx	IC Document
eligibility consent script_TAGALOG_No Inc.docx eligibility consent script_TAGALOG_No Inc.docx	IC Document
eligibility consent script_TAGALOG_No Inc.docx eligibility consent script_TAGALOG_No Inc.docx	IC Document
leave-behind consent_TAGALOG.docx leave-behind consent_TAGALOG.docx	IC Document
leave-behind consent_TAGALOG.docx leave-behind consent_TAGALOG.docx	IC Document
leave-behind consent_TAGALOG_No Inc.docx leave-behind consent_TAGALOG_No Inc.docx	IC Document
leave-behind consent_TAGALOG_No Inc.docx leave-behind consent_TAGALOG_No Inc.docx	IC Document
eligibility consent script_SAMOAN.docx eligibility consent script_SAMOAN.docx	IC Document
eligibility consent script_SAMOAN.docx eligibility consent script_SAMOAN.docx	IC Document
leave-behind consent_SAMOAN.docx leave-behind consent_SAMOAN.docx	IC Document
leave-behind consent_SAMOAN.docx leave-behind consent_SAMOAN.docx	IC Document
eligibility consent script_POHNPEIAN.docx eligibility consent script_POHNPEIAN.docx	IC Document
eligibility consent script_POHNPEIAN.docx eligibility consent script_POHNPEIAN.docx	IC Document
leave-behind consent_POHNPEIAN.docx leave-behind consent_POHNPEIAN.docx	IC Document
leave-behind consent_POHNPEIAN.docx leave-behind consent_POHNPEIAN.docx	IC Document
eligibility consent script_MARSHALLESE.docx eligibility consent script_MARSHALLESE.docx	IC Document
eligibility consent script_MARSHALLESE.docx eligibility consent script_MARSHALLESE.docx	IC Document
leave-behind consent_MARSHALLESE.docx leave-behind consent_MARSHALLESE.docx	IC Document
leave-behind consent_MARSHALLESE.docx leave-behind consent_MARSHALLESE.docx	IC Document
eligibility consent script_PALAUAN_No Inc.docx eligibility consent script_PALAUAN_No Inc.docx	IC Document
eligibility consent script_PALAUAN_No Inc.docx eligibility consent script_PALAUAN_No Inc.docx	IC Document
leave-behind consent_PALAUAN.docx leave-behind consent_PALAUAN.docx	IC Document
leave-behind consent_PALAUAN.docx leave-behind consent_PALAUAN.docx	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	questionnaire PR english.docx	questionnaire PR english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1 B	questionnaire PR spanish.docx	questionnaire PR spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2	questionnaire USVI english.docx	questionnaire USVI english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2 B	questionnaire USVI spanish.docx	questionnaire USVI spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3	questionnaire Guam english.docx	questionnaire Guam english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3 B	questionnaire Guam chuukese.docx	questionnaire Guam chuukese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3 C	questionnaire Guam tagalog.docx	questionnaire Guam tagalog.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4	questionnaire AS english.docx	questionnaire AS english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4 B	questionnaire AS samoan.docx	questionnaire AS samoan.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5	questionnaire FSM english.docx	questionnaire FSM english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5 B	questionnaire FSM chuukese.docx	questionnaire FSM chuukese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5 C	questionnaire FSM pohnpeian.docx	questionnaire FSM pohnpeian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6	questionnaire RMI english.docx	questionnaire RMI english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6 B	questionnaire RMI marshallese.docx	questionnaire RMI marshallese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7	questionnaire CNMI english.docx	questionnaire CNMI english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8	questionnaire Palau english.docx	questionnaire Palau english.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8 B	questionnaire Palau palauan.docx	questionnaire Palau palauan.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8 C	questionnaire Palau tagalog.docx	questionnaire Palau tagalog.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	0	7,303
Annual IC Time Burden (Hours)	2,002	-12	2,014
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.