Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence Parent-Child Assistance Program (P-CAP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Client Lost Post E Client Lost Post Exit	Form and Instruction	New	Available
Form Advocate Accountin Advocate Accounting of Tracing Activity	Form and Instruction	New	Available
Form Close Out CloseOut	Form and Instruction	New	Repair queued
Form ASI Exit ASI Exit	Form and Instruction	New	Available
Form Biannual Form Biannual Form	Form and Instruction	New	Available
Form Monthly Update Monthly Update	Form and Instruction	New	Available
Form Weekly Time Summar Weekly Time Summary	Form and Instruction	New	Available
Form Demographic Data Demographic Data	Form and Instruction	New	Available
Form ASI - Part B ASI - Part B	Form and Instruction	New	Available
Form ASI Part A ASI Part A	Form and Instruction	New	Available
Form CRSQ CRSQ	Form and Instruction	New	Available
PCAP Consent Form - Michigan site.doc	Supplementary Document	Uploaded 2010-02-02	Available
PCAP Consent Form - Southern California site.doc	Supplementary Document	Uploaded 2010-02-02	Available
Scan002 Final .pdf	Supplementary Document	Uploaded 2010-02-01	Available
Scan001.pdf	Supplementary Document	Uploaded 2010-02-01	Available
ICR_FASD_PCAP 2-2-10 clean version.doc	Supporting Statement B	Uploaded 2010-02-02	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Repair queued
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
Attachment II and III.zip	Supplementary Document	Uploaded 2009-10-27	Available
ICR_FASD_PCAP 2-2-10 clean version.doc	Supporting Statement A	Uploaded 2010-02-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191220	FASD P-CAP Client Lost Post Exit	Form and Instruction	New	Client Lost Post Exit
191219	FASD P-CAP Advocate Accounting of Tracing Activity	Form and Instruction	New	Advocate Accounting of Tracing Activity
191218	FASD P-CAP Close Out	Form and Instruction	New	CloseOut
191217	FASD P-CAP Exit ASI	Form and Instruction	New	ASI Exit
191216	FASD P-CAP Biannual	Form and Instruction	New	Biannual Form
191215	FASD P-CAP Monthly Updates	Form and Instruction	New	Monthly Update
191214	FASD P-CAP Weekly Time Summary	Form and Instruction	New	Weekly Time Summary
191213	FASD P-CAP Demographic Data	Form and Instruction	New	Demographic Data
191212	FASD P-CAP ASI - Part B	Form and Instruction	New	ASI - Part B
191211	FASD P-CAP ASI - Part A	Form and Instruction	New	ASI Part A
191210	FASD P-CAP CRSQ	Form and Instruction	New	CRSQ

ICR Details

OMB Control No: 0930-0309	ICR Reference No: 200911-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Fetal Alcohol Spectrum Disorder (FASD) Center for Excellence Parent-Child Assistance Program (P-CAP)
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: 02/03/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/04/2009
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2013	36 Months From Approved
Responses	13,651	0	0
Time Burden (Hours)	7,269	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The P-CAP intervention was developed for high risk women who misuse alcohol and drugs during pregnancy, and has been rated and officially recognized as a Promising Program by SAMHSA's National Registry of Effective Programs and Practices. P-CAP is a paraprofessional home visitation model for extremely high-risk women. The program uses a case management approach, an effective complement to traditional substance abuse treatment, and focuses not simply on reducing alcohol and drug use, but on reducing other risk behaviors and addressing health and social well-being of the mothers and their children. The goals of the program are to: (1) assist mothers in obtaining treatment, maintaining recovery, and resolving the complex problems associated with their substance use; (2) guarantee that the children are in a safe environment and receiving appropriate health care; (3) effectively link families with community resources; and (4) demonstrate successful strategies for working with this population in order to prevent the risk of future drug and alcohol-affected children.

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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:
	74 FR 18386	04/22/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 55048	10/26/2009
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
FASD P-CAP ASI - Part A	ASI Part A	ASI Part A
FASD P-CAP ASI - Part B	ASI - Part B	ASI - Part B
FASD P-CAP Advocate Accounting of Tracing Activity	Advocate Accounting of Tracing Activity	Advocate Accounting of Tracing Activity
FASD P-CAP Biannual	Biannual Form	Biannual Form
FASD P-CAP CRSQ	CRSQ	CRSQ
FASD P-CAP Client Lost Post Exit	Client Lost Post Exit	Client Lost Post Exit
FASD P-CAP Close Out	Close Out	CloseOut
FASD P-CAP Demographic Data	Demographic Data	Demographic Data
FASD P-CAP Exit ASI	ASI Exit	ASI Exit
FASD P-CAP Monthly Updates	Monthly Update	Monthly Update
FASD P-CAP Weekly Time Summary	Weekly Time Summary	Weekly Time Summary

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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	13,651	0	0	13,651	0	0
Annual Time Burden (Hours)	7,269	0	0	7,269	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: $420,661

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: 11/04/2009

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