Appendix A Table

Appendix A_Table 1.docx

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

Appendix A Table

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Appendix A – Table 1


Table 1: Estimate Annualized Burden Hours

Type of

Respondent


Form

Name


No. of

Respondents

No.

Responses

per

Respondent

Average

Burden per

Response

(in hours)

Burden Hours per Form

Total Burden Hours

Adult Parents- Puerto Rico

Screener

11,596

1

0.03

347.88

1472.88

Core

1,250

1

0.83

1,037.5

Jurisdiction Module

1,250

1

0.07

87.5

Adult Parents- U.S. Virgin Islands

Screener

2,435

1

0.03

73.05

343.05

Core

300

1

0.83

249

Jurisdiction Module

300

1

0.07

21

Adult Parents- Guam

Screener

1,304

1

0.03

39.12

444.12

Core

450

1

0.83

373.5

Jurisdiction Module

450

1

0.07

31.5

Adult Parents- American Samoa

Screener

426

1

0.03

12.78

232.78

Core

250

1

0.83

207.5

Jurisdiction Module

250

1

0.05

12.5

Adult Parents- Federated States of Micronesia

Screener

339

1

0.03

10.17

230.17

Core

250

1

0.83

207.5

Jurisdiction Module

250

1

0.05

12.5

Adult Parents- Marshall Islands

Screener

547

1

0.03

16.41

289.41

Core

300

1

0.83

249

Jurisdiction Module

300

1

0.08

24

Adult Parents- Northern Mariana Islands

Screener

470

1

0.03

14.1

241.6

Core

250

1

0.83

207.5

Jurisdiction Module

250

1

0.08

20

Adult Parents- Palau

Screener

467

1

0.03

14.01

226.51

Core

250

1

0.83

207.5

Jurisdiction Module

250

1

0.02

5

Total


17,584




3480.52


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