Information Collection

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

IC 235104 under ICR 202404-0906-002 · OMB 0906-0042.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-01-22 - Revision of a currently approved collection

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
Form 1 MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
01_Updated MCH Survey_PR_English Nov 2022.docx	Other-Survey
01_Updated MCH Survey_PR_English Nov 2022.docx	Other-Survey
02_Updated MCH Survey_PR_Spanish Nov 2022.docx	Other-Survey
02_Updated MCH Survey_PR_Spanish Nov 2022.docx	Other-Survey
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
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

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: 17,584

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	17,584	10,281	7,303
Annual IC Time Burden (Hours)	3,481	1,479	2,002
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.