The Consumer Level National Outcome Measures (NOMs)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Repair queued
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Repair queued
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
Form Attachment 3 Child, Adolescent Tool	Form and Instruction	New	Available
Form Attachment 2 Caregiver Tool	Form and Instruction	New	Available
Form Attachment 1 Adult Tool	Form and Instruction	New	Available
SAMHSA NOMs Response.doc	Supplementary Document	Uploaded 2007-04-19	Available
CMHS NOMs Supporting Statement rev 12-13.doc	Supporting Statement B	Uploaded 2006-12-15	Available
CMHS NOMs Supporting Statement rev 12-13.doc	Supporting Statement A	Uploaded 2006-12-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
46638	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46638	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46638	CMHS NOMs	Form and Instruction	New	Adult Tool
46637	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46637	CMHS NOMs	Form and Instruction	New	Adult Tool
46637	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46636	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46636	CMHS NOMs	Form and Instruction	New	Adult Tool
46636	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46635	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46635	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46635	CMHS NOMs	Form and Instruction	New	Adult Tool
46634	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46634	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46634	CMHS NOMs	Form and Instruction	New	Adult Tool
46633	CMHS NOMs	Form and Instruction	New	Child, Adolescent Tool
46633	CMHS NOMs	Form and Instruction	New	Caregiver Tool
46633	CMHS NOMs	Form and Instruction	New	Adult Tool
46632	The Consumer Level National Outcome Measures (NOMs)	Form and Instruction	New	Child, Adolescent Tool
46632	The Consumer Level National Outcome Measures (NOMs)	Form and Instruction	New	Caregiver Tool
46632	The Consumer Level National Outcome Measures (NOMs)	Form and Instruction	New	Adult Tool

ICR Details

OMB Control No: 0930-0285	ICR Reference No: 200701-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: The Consumer Level National Outcome Measures (NOMs)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 04/27/2007
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/04/2007
Terms of Clearance: Approved consistent with revisions in response to OMB questions and comments as outlined in SAMHSA memo (see supplementary documents).

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2010	36 Months From Approved
Responses	60,081	0	0
Time Burden (Hours)	14,293	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data activity is to provide a level of consistency with the NOMs domain in SAMHSA-wide data collection and reporting of performance measures across all of its Centers and programs. This particular activity will promote the use of consistent measures among CMHS programs, grantees and contractors funded through the Programs of Regional and National Significance (PRNS) and the Children Mental Health Initiative (CMHI) budget lines. The Consumer NOMs recommended by CMHS are a result of extensive examination and recommendations, by panels of staff, experts, and grantees. Wherever feasible, the proposed measures are consistent with or build upon previous data development efforts within CMHS.

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Authorizing Statute(s): EO: EO 1115 Name/Subject of EO: GPRA
  

Citations for New Statutory Requirements: US Code: 5 USC 501 Name of Law: SAMHSA

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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:
	71 FR 33476	06/09/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 75568	12/15/2006
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
CMHS NOMs	Attachment 1, Attachment 2, Attachment 3	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool
The Consumer Level National Outcome Measures (NOMs)	Attachment 2, Attachment 3, Attachment 1	Adult Tool ,   Caregiver Tool ,   Child, Adolescent Tool

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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	60,081	0	0	60,081	0	0
Annual Time Burden (Hours)	14,293	0	100,058	-85,765	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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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: 01/04/2007

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