Application/Annual Report with Needs Assessment Summary

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

Documents and Forms

Document Name Document Type
Form 1 Application/Annual Report with Needs Assessment Summary Form and Instruction
1 Title V Maternal and Child Health Services Block Grant t Title V Block Grant Guidance and Reporting Forms_ 30 Day Comment_Final_8.23.23.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

Information Collection (IC) Details

IC Title:	Application/Annual Report with Needs Assessment Summary	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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Title V Maternal and Child Health Services Block Grant to States Program Guidance Forms for the Title V Application/ Annual Report	0172 Revised Form 10.6.23.docx		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 %

	Approved	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	59	0	59
Annual IC Time Burden (Hours)	17,464	10,384	7,080
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.