Recovery Services for Adolescents and Families (RSAF)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Support Services S Support Services Supervisor Instruments	Form and Instruction	New	Available
Form Family Program Cli Family Program Clinician Instruments	Form and Instruction	New	Available
Form Social Network Sit Social Network Site Moderator	Form and Instruction	New	Available
Form Telephone Support Telephone Support Volunteer Instruments	Form and Instruction	New	Available
Form Project Coordinato Project Coordinator Instruments	Form and Instruction	New	Repair queued
Form Collateral Instrum Collateral Instruments	Form and Instruction	New	Available
Form Adolescent Instrum Adolescent Instruments	Form and Instruction	New	Repair queued
OMB_Supporting_Statement_4.doc	Supporting Statement B	Uploaded 2009-11-12	Available
Project Coordinator Other Attachments.zip	Supplementary Document	Uploaded 2009-11-12	Available
OMB_Supporting_Statement_4.doc	Supporting Statement A	Uploaded 2009-11-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
191562	RSAF - Support Services Supervisor	Form and Instruction	New	Support Services Supervisor Instruments
191561	RSAF - Family Program Clinician	Form and Instruction	New	Family Program Clinician Instruments
191560	RSAD - Social Network Site Moderator	Form and Instruction	New	Social Network Site Moderator
191559	RSAF - Telephone Support Volunteer	Form and Instruction	New	Telephone Support Volunteer Instruments
191558	RSAF - Project Coordinator	Form and Instruction	New	Project Coordinator Instruments
191557	RSAF - Collateral	Form and Instruction	New	Collateral Instruments
191556	RSAF - Adolescent	Form and Instruction	New	Adolescent Instruments

ICR Details

OMB Control No: 0930-0311	ICR Reference No: 200912-0930-003
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Recovery Services for Adolescents and Families (RSAF)
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 03/01/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/12/2009
Terms of Clearance: Withdrawn at the request of HHS/SAMHSA dated 3/1/2010.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		36 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: There will be 28 data collection forms used for gathering baseline and clinical data, monitoring preliminary outcomes, and monitoring implementation of the project's recovery support services. Adolescent participants will be asked to complete 3 forms, and collateral participants (parent/guardians) will be asked to complete 6 forms. Staff (consisting of Project Coordinators, Telephone Support Volunteers, Social Networking Site Moderators, Family Support Clinicians, and Support Services Supervisors) will be asked to complete 19 unique forms, with no individual completing more than 7 forms.

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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 22936	05/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 59549	11/18/2009
Did the Agency receive public comments on this ICR? No

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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
RSAD - Social Network Site Moderator	Social Network Site Moderator	Social Network Site Moderator
RSAF - Telephone Support Volunteer	Telephone Support Volunteer Instruments	Telephone Support Volunteer Instruments
RSAF - Adolescent	Adolescent Instruments	Adolescent Instruments
RSAF - Collateral	Collateral Instruments	Collateral Instruments
RSAF - Family Program Clinician	Family Program Clinician Instruments	Family Program Clinician Instruments
RSAF - Project Coordinator	Project Coordinator Instruments	Project Coordinator Instruments
RSAF - Support Services Supervisor	Support Services Supervisor Instruments	Support Services Supervisor Instruments

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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: $1,197,336

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: 12/12/2009

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