Information Collection

Application/Annual Report with Needs Assessment Summary

IC 6398 under ICR 202309-0915-006 · OMB 0915-0172.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0915-0172 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Application/Annual Report with Needs Assessment Summary	Form and Instruction
1 Title V Maternal and Child Health Services Block Grant t Title V Block Grant Guidance and Reporting Forms_ 30 Day Comment_Final_8.23.23.docx	Form and Instruction
1 Title V Maternal and Child Health Services Block Grant t 0172 Revised Form 10.6.23.docx	Form and Instruction

IC Title:

Application/Annual Report with Needs Assessment Summary

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	1	Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report	0172 Revised Form 10.6.23.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

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	59	0	59
Annual IC Time Burden (Hours)	17,464	10,384	7,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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