Information Collection

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

IC 235104 under ICR 202501-0906-003 · OMB 0906-0042.

Documents and Forms

Document Name Document Type
Form 1a MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program Form and Instruction
1a MCH-JS Survey_2024_American Samoa_English.docx MCH-JS Survey_2024_American Samoa_English.docx Form and Instruction
1a MCH-JS Survey_2024_American Samoa_English.docx MCH-JS Survey_2025_American Samoa_English.docx Form and Instruction
1b MCH-JS Survey_2024_American Samoa_Samoan MCH-JS Survey_2024_American Samoa_Samoan.docx Form and Instruction
1b MCH-JS Survey_2024_American Samoa_Samoan MCH-JS Survey_2025_American Samoa_Samoan.docx Form and Instruction
2a MCH-JS Survey_2024_CNMI_English MCH-JS Survey_2024_CNMI_English.docx Form and Instruction
2a MCH-JS Survey_2024_CNMI_English MCH-JS Survey_2025_CNMI_English.docx Form and Instruction
3a MCH-JS Survey_2024_FSM_Chuukese MCH-JS Survey_2024_FSM_Chuukese.docx Form and Instruction
3a MCH-JS Survey_2024_FSM_Chuukese MCH-JS Survey_2025_FSM_Chuukese.docx Form and Instruction
3b MCH-JS Survey_2024_FSM_English MCH-JS Survey_2024_FSM_English.docx Form and Instruction
3b MCH-JS Survey_2024_FSM_English MCH-JS Survey_2025_FSM_English.docx Form and Instruction
3c MCH-JS Survey_2024_FSM_Pohnpeian MCH-JS Survey_2024_FSM_Pohnpeian.docx Form and Instruction
3c MCH-JS Survey_2024_FSM_Pohnpeian MCH-JS Survey_2025_FSM_Pohnpeian.docx Form and Instruction
4a MCH-JS Survey_2024_Guam_English MCH-JS Survey_2024_Guam_English.docx Form and Instruction
4a MCH-JS Survey_2024_Guam_English MCH-JS Survey_2025_Guam_English.docx Form and Instruction
4b MCH-JS Survey_2024_Guam_Tagalog MCH-JS Survey_2024_Guam_Tagalog.docx Form and Instruction
4b MCH-JS Survey_2024_Guam_Tagalog MCH-JS Survey_2025_Guam_Tagalog.docx Form and Instruction
5a MCH-JS Survey_2024_Palau_English MCH-JS Survey_2024_Palau_English.docx Form and Instruction
5a MCH-JS Survey_2024_Palau_English MCH-JS Survey_2025_Palau_English.docx Form and Instruction
5b MCH-JS Survey_2024_Palau_Palaun MCH-JS Survey_2024_Palau_Palaun.docx Form and Instruction
5b MCH-JS Survey_2024_Palau_Palaun MCH-JS Survey_2025_Palau_Palaun.docx Form and Instruction
5c MCH-JS Survey_2024_Palau_Tagalog MCH-JS Survey_2024_Palau_Tagalog.docx Form and Instruction
5c MCH-JS Survey_2024_Palau_Tagalog MCH-JS Survey_2025_Palau_Tagalog.docx Form and Instruction
6a MCH-JS Survey_2024_Puerto Rico_English MCH-JS Survey_2024_Puerto Rico_English.docx Form and Instruction
6a MCH-JS Survey_2024_Puerto Rico_English MCH-JS Survey_2025_Puerto Rico_English.docx Form and Instruction
6b MCH-JS Survey_2024_Puerto Rico_Spanish MCH-JS Survey_2024_Puerto Rico_Spanish.docx Form and Instruction
6b MCH-JS Survey_2024_Puerto Rico_Spanish MCH-JS Survey_2025_Puerto Rico_Spanish.docx Form and Instruction
7a MCH-JS Survey_2024_RMI_English MCH-JS Survey_2024_RMI_English.docx Form and Instruction
7a MCH-JS Survey_2024_RMI_English MCH-JS Survey_2025_RMI_English.docx Form and Instruction
7b MCH-JS Survey_2024_RMI_Marshallese MCH-JS Survey_2024_RMI_Marshallese.docx Form and Instruction
7b MCH-JS Survey_2024_RMI_Marshallese MCH-JS Survey_2025_RMI_Marshallese.docx Form and Instruction
8a MCH-JS Survey_2024_USVI_English MCH-JS Survey_2024_USVI_English.docx Form and Instruction
8a MCH-JS Survey_2024_USVI_English MCH-JS Survey_2025_USVI_English.docx Form and Instruction
8b MCH-JS Survey_2024_USVI_Spanish MCH-JS Survey_2024_USVI_Spanish.docx Form and Instruction
8b MCH-JS Survey_2024_USVI_Spanish MCH-JS Survey_2025_USVI_Spanish.docx Form and Instruction
4c MCH-JS Survey_2024_Guam_Chuukese MCH-JS Survey_2024_Guam_Chuukese.docx Form and Instruction
4c MCH-JS Survey_2024_Guam_Chuukese MCH-JS Survey_2025_Guam_Chuukese.docx Form and Instruction
eligibility consent script_CHUUKESE.docx eligibility consent script_CHUUKESE IC Document
eligibility consent script_CHUUKESE.docx eligibility consent script_CHUUKESE IC Document
eligibility consent script_ENGLISH.docx eligibility consent script_ENGLISH IC Document
eligibility consent script_ENGLISH.docx eligibility consent script_ENGLISH IC Document
eligibility consent script_ENGLISH_No Inc.docx eligibility consent script_ENGLISH_No Inc IC Document
eligibility consent script_ENGLISH_No Inc.docx eligibility consent script_ENGLISH_No Inc IC Document
eligibility consent script_MARSHALLESE.docx eligibility consent script_MARSHALLESE IC Document
eligibility consent script_MARSHALLESE.docx eligibility consent script_MARSHALLESE IC Document
eligibility consent script_PALAUAN_No Inc.docx eligibility consent script_PALAUAN_No Inc IC Document
eligibility consent script_PALAUAN_No Inc.docx eligibility consent script_PALAUAN_No Inc IC Document
eligibility consent script_POHNPEIAN.docx eligibility consent script_POHNPEIAN IC Document
eligibility consent script_POHNPEIAN.docx eligibility consent script_POHNPEIAN IC Document
eligibility consent script_SAMOAN.docx eligibility consent script_SAMOAN IC Document
eligibility consent script_SAMOAN.docx eligibility consent script_SAMOAN IC Document
eligibility consent script_SPANISH.docx eligibility consent script_SPANISH IC Document
eligibility consent script_SPANISH.docx eligibility consent script_SPANISH IC Document
eligibility consent script_TAGALOG.docx eligibility consent script_TAGALOG IC Document
eligibility consent script_TAGALOG.docx eligibility consent script_TAGALOG IC Document
eligibility consent script_TAGALOG_No Inc.docx eligibility consent script_TAGALOG_No Inc IC Document
eligibility consent script_TAGALOG_No Inc.docx eligibility consent script_TAGALOG_No Inc IC Document
leave-behind consent_CHUUKESE.docx leave-behind consent_CHUUKESE IC Document
MCH_JS_2025_leave-behind consent_CHUUKESE.docx leave-behind consent_CHUUKESE IC Document
leave-behind consent_ENGLISH.docx leave-behind consent_ENGLISH IC Document
MCH-JS_2025_leave-behind consent_ENGLISH.docx leave-behind consent_ENGLISH IC Document
leave-behind consent_ENGLISH_No Inc.docx leave-behind consent_ENGLISH_No Inc IC Document
MCH-JS_2025_leave-behind consent_ENGLISH_No Inc.docx leave-behind consent_ENGLISH_No Inc IC Document
leave-behind consent_MARSHALLESE.docx leave-behind consent_MARSHALLESE IC Document
MCH-JS_2025_leave-behind consent_MARSHALLESE.docx leave-behind consent_MARSHALLESE IC Document
leave-behind consent_PALAUAN.docx leave-behind consent_PALAUAN IC Document
MCH-JS_2025_leave-behind consent_PALAUAN.docx leave-behind consent_PALAUAN IC Document
leave-behind consent_POHNPEIAN.docx leave-behind consent_POHNPEIAN IC Document
MCH-JS_2025_leave-behind consent_POHNPEIAN.docx leave-behind consent_POHNPEIAN IC Document
leave-behind consent_SAMOAN.docx leave-behind consent_SAMOAN IC Document
MCH-JS_2025_leave-behind consent_SAMOAN.docx leave-behind consent_SAMOAN IC Document
leave-behind consent_SPANISH.DOCX leave-behind consent_SPANISH IC Document
MCH-JS_2025_leave-behind consent_SPANISH.DOCX leave-behind consent_SPANISH IC Document
leave-behind consent_TAGALOG.docx leave-behind consent_TAGALOG IC Document
MCH-JS_2025_leave-behind consent_TAGALOG.docx leave-behind consent_TAGALOG IC Document
leave-behind consent_TAGALOG_No Inc.docx leave-behind consent_TAGALOG No Inc IC Document
MCH_JS_2025_leave-behind consent_TAGALOG_No Inc.docx leave-behind consent_TAGALOG No Inc 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:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1a	MCH-JS Survey_2024_American Samoa_English.docx	MCH-JS Survey_2025_American Samoa_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	1b	MCH-JS Survey_2024_American Samoa_Samoan	MCH-JS Survey_2025_American Samoa_Samoan.docx	Yes	Yes	Fillable Fileable
Form and Instruction	2a	MCH-JS Survey_2024_CNMI_English	MCH-JS Survey_2025_CNMI_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3a	MCH-JS Survey_2024_FSM_Chuukese	MCH-JS Survey_2025_FSM_Chuukese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3b	MCH-JS Survey_2024_FSM_English	MCH-JS Survey_2025_FSM_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	3c	MCH-JS Survey_2024_FSM_Pohnpeian	MCH-JS Survey_2025_FSM_Pohnpeian.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4a	MCH-JS Survey_2024_Guam_English	MCH-JS Survey_2025_Guam_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4b	MCH-JS Survey_2024_Guam_Tagalog	MCH-JS Survey_2025_Guam_Tagalog.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5a	MCH-JS Survey_2024_Palau_English	MCH-JS Survey_2025_Palau_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5b	MCH-JS Survey_2024_Palau_Palaun	MCH-JS Survey_2025_Palau_Palaun.docx	Yes	Yes	Fillable Fileable
Form and Instruction	5c	MCH-JS Survey_2024_Palau_Tagalog	MCH-JS Survey_2025_Palau_Tagalog.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6a	MCH-JS Survey_2024_Puerto Rico_English	MCH-JS Survey_2025_Puerto Rico_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	6b	MCH-JS Survey_2024_Puerto Rico_Spanish	MCH-JS Survey_2025_Puerto Rico_Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7a	MCH-JS Survey_2024_RMI_English	MCH-JS Survey_2025_RMI_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	7b	MCH-JS Survey_2024_RMI_Marshallese	MCH-JS Survey_2025_RMI_Marshallese.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8a	MCH-JS Survey_2024_USVI_English	MCH-JS Survey_2025_USVI_English.docx	Yes	Yes	Fillable Fileable
Form and Instruction	8b	MCH-JS Survey_2024_USVI_Spanish	MCH-JS Survey_2025_USVI_Spanish.docx	Yes	Yes	Fillable Fileable
Form and Instruction	4c	MCH-JS Survey_2024_Guam_Chuukese	MCH-JS Survey_2025_Guam_Chuukese.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: 14,500	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	14,500	-3,084	17,584
Annual IC Time Burden (Hours)	3,155	-326	3,481
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.