Information Collection

Application/Annual Report with Needs Assessment Summary

IC 6398 under ICR 202503-0915-002 · OMB 0915-0172.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Application/Annual Report with Needs Assessment Summary	Form and Instruction
Form 1 Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report Application/Annual Report with Needs Assessment Summary	Form and Instruction
Form 1 (03.25 Version) MCHB_Guidance and Forms for the Title V Application Annual Report Application/Annual Report with Needs Assessment Summary	Form and Instruction
1 Title V Maternal and Child Health Services Block Grant t 0172 Revised Form 10.6.23.docx	Form and Instruction
1 Title V Maternal and Child Health Services Block Grant t 0172 Revised Form 10.6.23.docx	Form and Instruction
1 (03.25 Version) MCHB_Guidance and Forms for the Title V Application Annu 1B_MCHB_0915-0172_MCHB_Guidance and Forms for the Title V Application Annual Report REDLINE.docx	Form and Instruction
1 (03.25 Version) MCHB_Guidance and Forms for the Title V Application Annu 1B_MCHB_0915-0172_MCHB_Guidance and Forms for the Title V Application Annual Report REDLINE.docx	Form and Instruction

IC Title:

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1				Yes	Yes	Fillable Fileable
Form and Instruction	1 (03.25 Version)				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 59

Number of Respondents for Small Entity: 0

Affected Public: State, Local, and Tribal Governments

Percentage of Respondents Reporting Electronically: 100 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	59	59
Annual IC Time Burden (Hours)	17,464	17,464
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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

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