Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Project CHOICES

Forms and Documents

Document Name	Status
Form Attachment I FASD - CHOICES Form and Instruction	New
FASD OMB Supporting Statement Proj CHOICES_v3.doc Supporting Statement B	2009-07-13
Consent Forms- Attachment III.zip Supplementary Document	2009-07-13
List of sites- Attachment II.doc Supplementary Document	2009-07-13
FASD OMB Supporting Statement Proj CHOICES_v3.doc Supporting Statement A	2009-07-13

IC Document Collections

IC ID	Document Title	Status
189906	FASD - CHOICES Form and Instruction	New

ICR Details

OMB Control No: 0930-0303	ICR Reference No: 200907-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Project CHOICES
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 without change	Conclusion Date: 09/15/2009
	Date Received in OIRA: 07/15/2009
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2012	36 Months From Approved
Responses	5,701	0	0
Time Burden (Hours)	844	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This data collection effort will use seven data collection instruments. The purposes of the data collection activities are to: 1) determine whether Project CHOICES interventions were provided (and to document the details of the intervention as they are integrated), and 2) assess the extent to which women achieved the desired outcomes (abstinence from alcohol use and consistent and correct use of contraceptive methods). In order to assess these broad goals, specific outcome and process questions have been devised.

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Authorizing Statute(s): US Code: 5 USC 501 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 74728	12/09/2008
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 33446	07/13/2009
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
FASD - CHOICES	Attachment I	Forms

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ICR Summary 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	5,701	0	0	5,701	0	0
Annual Time Burden (Hours)	844	0	0	844	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 project.

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Annual Cost to Federal Government: $1,000,136

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)? No

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: 07/15/2009

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