Maternal and Child Health Services Block Grant Application/Annual Report Guidance

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 (03.25 Version) MCHB_Guidance and Forms for the Title V Application Annual Report	Form and Instruction	Modified	Available
Form 1 Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report	Form and Instruction	Modified	Available
Form 1 Application/Annual Report with Needs Assessment Summary	Form and Instruction	Modified	Missing upstream
1A_MCHB_0915-0172_MCHB_Table of Proposed Changes.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-26	Available
1A_MCHB_0915-0172_MCHB_Table of Proposed Changes.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-26	Repair queued
1_MCHB_0915-0172_OMB NonSubstantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-26	Available
1_MCHB_0915-0172_OMB NonSubstantive Change Request.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2025-03-26	Repair queued
Final SSA 0172 Clean.docx	Supporting Statement A	Uploaded 2023-09-28	Available
Final SSA 0172 Clean.docx	Supporting Statement A	Uploaded 2023-09-28	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
6398	Application/Annual Report with Needs Assessment Summary	Form and Instruction	Modified	MCHB_Guidance and Forms for the Title V Application Annual Report
6398	Application/Annual Report with Needs Assessment Summary	Form and Instruction	Modified	Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report
6398	Application/Annual Report with Needs Assessment Summary	Form and Instruction	Modified

ICR Details

OMB Control No: 0915-0172	ICR Reference No: 202503-0915-002
Status: Active	Previous ICR Reference No: 202309-0915-006
Agency/Subagency: HHS/HSA	Agency Tracking No:
Title: Maternal and Child Health Services Block Grant Application/Annual Report Guidance
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/18/2025
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/28/2025
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2026	12/31/2026	12/31/2026
Responses	59	0	59
Time Burden (Hours)	17,464	0	17,464
Cost Burden (Dollars)	0	0	0

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Abstract: The Application and Annual Report fulfill the requirements of Section 505 and Section 506, respectively, of the Title V legislation. Consistent with previous editions, the updated Application/Annual Report Guidance is designed to allow states flexibility in meeting the unique needs of their MCH populations while enabling the Maternal and Child Health Bureau (MCHB) to meet the Title V legislative requirements, collect and utilize comparative data for addressing national and state MCH priorities, and demonstrate accountability in the use of the Federal Title V funds. The MCHB, in the Health Resources and Services Administration (HRSA), serves as the Health and Human Services (HHS) Secretary’s delegate to collect this information and to review it prior to the award of approximately $581 million annually in state formula grants under the MCH Block Grant. This is a revision request.

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Authorizing Statute(s): PL: Pub.L. 101 - 239 501 Name of Law: Social Security Act of 1935
  

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:
	88 FR 29135	05/05/2023
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 63963	09/18/2023
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Application/Annual Report with Needs Assessment Summary	1, 1 (03.25 Version)	Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report ,   MCHB_Guidance and Forms for the Title V Application Annual Report

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ICR Summary of Burden

table that charts list of burden

	Total Approved	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	59	59	0	0	0	0
Annual Time Burden (Hours)	17,464	17,464	0	0	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: No

Burden Reduction Due to:

Short Statement: The current inventory for this activity in a year in which States do not report on the findings of a Five-year Needs Assessment is 6,785 hours. In a year in which the state submits a Five-Year Needs Assessment Summary as part of its Application/Annual Report, the current estimate is 10,679 hours. The three-year period to be covered by the updated Application/Annual Report Guidance will include the submission of a Five-Year Needs Assessment Summary. Updates to the Application/Annual Report that contribute to the anticipated reduction in effort are: • Streamlined narrative reporting for the State MCH Block Grant Application/Annual Report and the SSDI annual performance and progress reports; • Clearer instructions for completing reporting forms; • Development of a technical resource document that includes updated references, a complete glossary, added resources, tools, state examples and supportive background information; and • Continued enhancements to the TVIS. Both the Application and Annual Report w/o, and with, the Five-Year Needs Assessment Summary.

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Annual Cost to Federal Government: $355,625

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 03/28/2025

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