Information Collection Request

Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program

ICR 202211-0906-001 · OMB 0906-0042 · Active

⚠️ Notice: This information collection may be outdated. More recent filings for OMB 0906-0042 can be found here:

Forms and Documents

Forms and supporting documents for this ICR
Document	Type	Status	Availability
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified	Available
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified	Repair queued
Jurisdictional Survey OMB Request for Non-Substantive Change_OMB_Final_11.1.22.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-11-10	Available
Jurisdictional Survey OMB Request for Non-Substantive Change_OMB_Final_11.1.22.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2022-11-10	Repair queued
Supporting Statement B.docx	Supporting Statement B	Uploaded 2022-03-09	Available
Supporting Statement B.docx	Supporting Statement B	Uploaded 2022-03-09	Repair queued
Supporting Statement A Updated 03312022.docx	Supporting Statement A	Uploaded 2022-03-31	Available
Supporting Statement A Updated 03312022.docx	Supporting Statement A	Uploaded 2022-03-31	Missing upstream

Information collection document groups
IC ID	Collection	Type	Status	Form
235104	MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified
235104	MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified

Record metadata
Status	Active
Agency/Subagency	HHS/HRSA
OMB Control No	0906-0042
Type of Information Collection	No material or nonsubstantive change to a currently approved collection
Previous ICR Reference No	202203-0906-002
Date Submitted to OIRA	2022-11-10
Requested Expiration Date	1969-12-31