Opioid Treatment Program (OTP) Mortality Reporting Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form OTP Mortality Repo OTP	Form and Instruction	New	Available
Revised Burden Table.doc	Supplementary Document	Uploaded 2008-10-26	Available
Supporting Statement.doc	Supporting Statement B	Uploaded 2008-05-15	Available
Attachment E.doc	Supplementary Document	Uploaded 2008-05-15	Available
Attachment D.doc	Supplementary Document	Uploaded 2008-05-15	Available
Attachment B.doc	Supplementary Document	Uploaded 2008-05-15	Available
Attachment A.doc	Supplementary Document	Uploaded 2008-05-15	Available
Supporting Statement.doc	Supporting Statement A	Uploaded 2008-05-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
184923	OTP	Form and Instruction	New

ICR Details

OMB Control No: 0930-0296	ICR Reference No: 200805-0930-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Opioid Treatment Program (OTP) Mortality Reporting Form
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: 10/28/2008
	Date Received in OIRA: 05/15/2008
Terms of Clearance: Approved consistent with revisions to the burden table.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2011	36 Months From Approved
Responses	2,300	0	0
Time Burden (Hours)	1,150	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The OTP Mortality Reporting Form allows OTPs to voluntarily report mortality data on patients who at the time of death, were on a medication-assisted treatment (methadone or buprenorphine) in a SAMHSA-certified OTP.

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Authorizing Statute(s): US Code: 5 USC 290aa Name of Law: SAMHSA
  

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:
	73 FR 200	01/02/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	73 FR 28126	05/15/2008
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
OTP	OTP Mortality Reporting Form	Attachment C - OTP Mortality Reporting Form

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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	2,300	0	0	2,300	0	0
Annual Time Burden (Hours)	1,150	0	0	1,150	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: No

Burden Reduction Due to:

Short Statement: This is a new data collection.

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Annual Cost to Federal Government: $130,469

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: 05/15/2008

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