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

Forms and Documents

Document	Type	Status	Availability
Form 1a MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction	Modified	Repair queued
Attachment B - Summary of Survey Additions and Deletions MCHB - MCH Jurisdictional Survey - Revision.docx	Supplementary Document	Uploaded 2025-01-21	Repair queued
Attachment A - Measure and Survey Crosswalk - MCHB - MCH Jurisdictional Survey - Revision.docx	Supplementary Document	Uploaded 2025-01-21	Repair queued
Supporting Statement B - MCHB - MCH Jurisdictional Survey - Rev 011525.docx	Supporting Statement B	Uploaded 2025-01-21	Repair queued
Supporting Statement A - MCHB - MCH Jurisdictional Survey - Rev 012125.docx	Supporting Statement A	Uploaded 2025-01-21	Repair queued

IC Document Collections

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

ICR Details

OMB Control No: 0906-0042	ICR Reference No: 202501-0906-003
Status: Received in OIRA	Previous ICR Reference No: 202404-0906-002
Agency/Subagency: HHS/HRSA	Agency Tracking No:
Title: Maternal and Child Health Jurisdictional Survey Instrument for the Title V MCH Block Grant Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 01/22/2025

	Requested	Previously Approved
Expiration Date	36 Months From Approved	04/30/2025
Responses	14,500	17,584
Time Burden (Hours)	3,155	3,481
Cost Burden (Dollars)	0	0

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Abstract: HRSA/MCHB needs the Title V MCH Block Grant Jurisdictional MCH Survey to create a mechanism for jurisdictions to collect, report, and monitor key MCH indicators over time. This data collection will enable the eight jurisdictions (i.e., American Samoa, Federated States of Micronesia, Guam, Marshall Islands, Northern Mariana Islands, Palau, Puerto Rico, and U.S. Virgin Islands) to meet Federal performance reporting requirements and to demonstrate the impact of Title V funding relative to MCH outcomes for the U.S. jurisdictions in reporting on their unique MCH priority needs. Having these data will allow for better annual reporting by the Federal program office in reporting to Congress on the jurisdictions’ Title V program accomplishments.

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Authorizing Statute(s): US Code: 5 USC 5 CFR 1320.5(d)(2) Name of Law: Controlling Paperwork Burdens on the Public
   US Code: 42 USC 701 et seq. Name of Law: Maternal and Child Health Services Block Grant programs
  

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 86822	10/31/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	90 FR 5913	01/17/2025
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	1a, 1b, 2a, 3a, 3b, 3c, 4a, 4b, 5a, 5b, 5c, 6a, 6b, 7a, 7b, 8a, 8b, 4c	MCH-JS Survey_2024_American Samoa_English.docx ,   MCH-JS Survey_2024_American Samoa_Samoan ,   MCH-JS Survey_2024_CNMI_English ,   MCH-JS Survey_2024_FSM_Chuukese ,   MCH-JS Survey_2024_FSM_English ,   MCH-JS Survey_2024_FSM_Pohnpeian ,   MCH-JS Survey_2024_Guam_English ,   MCH-JS Survey_2024_Guam_Tagalog ,   MCH-JS Survey_2024_Palau_English ,   MCH-JS Survey_2024_Palau_Palaun ,   MCH-JS Survey_2024_Palau_Tagalog ,   MCH-JS Survey_2024_Puerto Rico_English ,   MCH-JS Survey_2024_Puerto Rico_Spanish ,   MCH-JS Survey_2024_RMI_English ,   MCH-JS Survey_2024_RMI_Marshallese ,   MCH-JS Survey_2024_USVI_English ,   MCH-JS Survey_2024_USVI_Spanish ,   MCH-JS Survey_2024_Guam_Chuukese

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ICR Summary of Burden

	Total Request	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	14,500	17,584	0	-3,084	0	0
Annual Time Burden (Hours)	3,155	3,481	0	-326	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The estimated annual burden in this revision package is 3,155 hours, a decrease from the previously estimated 3,481 hours in ICR 202404-0906-002. Although the total number of interviews has increased, the burden hours have declined due to two factors: (1) survey timings have been adjusted to reflect actual survey times from the three completed rounds of data collection, rather than prior estimates, and (2) eligibility assumptions and response rates have been updated based on actual results from the same three rounds of data collection experience.

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Annual Cost to Federal Government: $1,189,364

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? No

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 01/22/2025

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