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

Documents and forms in this information collection
Document Name	Document Type
Form 1a MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 1a MCH-JS Survey_2024_American Samoa_English.docx MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 1b MCH-JS Survey_2024_American Samoa_Samoan MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 2a MCH-JS Survey_2024_CNMI_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 3a MCH-JS Survey_2024_FSM_Chuukese MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 3b MCH-JS Survey_2024_FSM_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 3c MCH-JS Survey_2024_FSM_Pohnpeian MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 4a MCH-JS Survey_2024_Guam_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 4b MCH-JS Survey_2024_Guam_Tagalog MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 5a MCH-JS Survey_2024_Palau_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 5b MCH-JS Survey_2024_Palau_Palaun MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 5c MCH-JS Survey_2024_Palau_Tagalog MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 6a MCH-JS Survey_2024_Puerto Rico_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 6b MCH-JS Survey_2024_Puerto Rico_Spanish MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 7a MCH-JS Survey_2024_RMI_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 7b MCH-JS Survey_2024_RMI_Marshallese MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 8a MCH-JS Survey_2024_USVI_English MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 8b MCH-JS Survey_2024_USVI_Spanish MCH Jurisdictional Survey Instrument for the Title V MCH Block Grant Program	Form and Instruction
Form 4c MCH-JS Survey_2024_Guam_Chuukese 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:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1a	Yes	Yes	Fillable Fileable
Form and Instruction	1b	Yes	Yes	Fillable Fileable
Form and Instruction	2a	Yes	Yes	Fillable Fileable
Form and Instruction	3a	Yes	Yes	Fillable Fileable
Form and Instruction	3b	Yes	Yes	Fillable Fileable
Form and Instruction	3c	Yes	Yes	Fillable Fileable
Form and Instruction	4a	Yes	Yes	Fillable Fileable
Form and Instruction	4b	Yes	Yes	Fillable Fileable
Form and Instruction	5a	Yes	Yes	Fillable Fileable
Form and Instruction	5b	Yes	Yes	Fillable Fileable
Form and Instruction	5c	Yes	Yes	Fillable Fileable
Form and Instruction	6a	Yes	Yes	Fillable Fileable
Form and Instruction	6b	Yes	Yes	Fillable Fileable
Form and Instruction	7a	Yes	Yes	Fillable Fileable
Form and Instruction	7b	Yes	Yes	Fillable Fileable
Form and Instruction	8a	Yes	Yes	Fillable Fileable
Form and Instruction	8b	Yes	Yes	Fillable Fileable
Form and Instruction	4c	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 %

table that charts list of burden
	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

table that charts IC Documents
Title	Document	Date Uploaded
eligibility consent script_CHUUKESE		02/19/2025
eligibility consent script_ENGLISH		02/19/2025
eligibility consent script_ENGLISH_No Inc		02/19/2025
eligibility consent script_MARSHALLESE		02/19/2025
eligibility consent script_PALAUAN_No Inc		02/19/2025
eligibility consent script_POHNPEIAN		02/19/2025
eligibility consent script_SAMOAN		02/19/2025
eligibility consent script_SPANISH		02/19/2025
eligibility consent script_TAGALOG		02/19/2025
eligibility consent script_TAGALOG_No Inc		02/19/2025
leave-behind consent_CHUUKESE		02/19/2025
leave-behind consent_ENGLISH		02/19/2025
leave-behind consent_ENGLISH_No Inc		02/19/2025
leave-behind consent_MARSHALLESE		02/19/2025
leave-behind consent_PALAUAN		02/19/2025
leave-behind consent_POHNPEIAN		02/19/2025
leave-behind consent_SAMOAN		02/19/2025
leave-behind consent_SPANISH		02/19/2025
leave-behind consent_TAGALOG		02/19/2025
leave-behind consent_TAGALOG No Inc		02/19/2025

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

Something went wrong when downloading this file. If you have any questions, please send an email to [email protected].