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Federal forms, ICRs, and supporting documents

Information Collection

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

IC 235104 under ICR 202211-0906-001 · OMB 0906-0042.

Documents and Forms
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Form and Instruction
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Information Collection (IC) Details

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MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
 
No Modified
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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
Other-Survey 01_Updated MCH Survey_PR_English Nov 2022.docx Yes Yes Fillable Fileable
Other-Survey 02_Updated MCH Survey_PR_Spanish Nov 2022.docx Yes Yes Fillable Fileable

Health Public Health Monitoring

 

7,303 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 7,303 0 0 0 0 7,303
Annual IC Time Burden (Hours) 2,002 0 0 0 0 2,002
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Eligibility and Consent Script English MCH Survey Eligibility and Consent Script_ENGLISH.docx 03/09/2022
MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx MCH Survey Eligibility and Consent Script_No Inc_ENGLISH.docx 03/09/2022
MCH Survey Leave-Behind Consent_ENGLISH.docx MCH Survey Leave-Behind Consent_ENGLISH.docx 03/09/2022
MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx MCH Survey Leave-Behind Consent_No Incentive_ENGLISH.docx 03/09/2022
eligibility consent script_SPANISH eligibility consent script_SPANISH.docx 03/09/2022
leave-behind consent_SPANISH.DOCX leave-behind consent_SPANISH.DOCX 03/09/2022
eligibility consent script_CHUUKESE.docx eligibility consent script_CHUUKESE.docx 03/09/2022
leave-behind consent_CHUUKESE.docx leave-behind consent_CHUUKESE.docx 03/09/2022
eligibility consent script_TAGALOG.docx eligibility consent script_TAGALOG.docx 03/09/2022
eligibility consent script_TAGALOG_No Inc.docx eligibility consent script_TAGALOG_No Inc.docx 03/09/2022
leave-behind consent_TAGALOG.docx leave-behind consent_TAGALOG.docx 03/09/2022
leave-behind consent_TAGALOG_No Inc.docx leave-behind consent_TAGALOG_No Inc.docx 03/09/2022
eligibility consent script_SAMOAN.docx eligibility consent script_SAMOAN.docx 03/09/2022
leave-behind consent_SAMOAN.docx leave-behind consent_SAMOAN.docx 03/09/2022
eligibility consent script_POHNPEIAN.docx eligibility consent script_POHNPEIAN.docx 03/09/2022
leave-behind consent_POHNPEIAN.docx leave-behind consent_POHNPEIAN.docx 03/09/2022
eligibility consent script_MARSHALLESE.docx eligibility consent script_MARSHALLESE.docx 03/09/2022
leave-behind consent_MARSHALLESE.docx leave-behind consent_MARSHALLESE.docx 03/09/2022
eligibility consent script_PALAUAN_No Inc.docx eligibility consent script_PALAUAN_No Inc.docx 03/09/2022
leave-behind consent_PALAUAN.docx leave-behind consent_PALAUAN.docx 03/09/2022
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.