Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Diagnosis and Intervention Project

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form K - Dx Int Lo Form K - Dx Int Lost Follow-up	Form and Instruction	New	Available
Form Form J - DxInt. Ou Form J - DxInt. Outcomes J. 8-18yrs.	Form and Instruction	New	Available
Form Form I - DxInt. Ou Form I - DxInt. Outcomes	Form and Instruction	New	Available
Form Form H - DxInt.CSS Form H - DxInt.CSS	Form and Instruction	New	Available
Form Form G - DxInt. Im Form G - DxInt. Improvement Measure	Form and Instruction	New	Available
Form Form F - DxInt. Im Form F - DxInt. Improvement Measure	Form and Instruction	New	Available
Form Form E - DxInt.Ser Form E - DxInt.Service Tracking	Form and Instruction	New	Available
Form Form D - DxInt.Ser Form D - DxInt.Service Provided After Diag.	Form and Instruction	New	Available
Form Form C - DxInt. Se Form C - DxInt. Services Provided at Diag	Form and Instruction	New	Available
Form Form B - DxInt. Po Form B - DxInt. Positive Monitor Tracking	Form and Instruction	New	Available
Form Form A - DxInt. Sc Form A - DxInt. Screening	Form and Instruction	New	Available
FASD_DxInt Supporting_Statement3.25.2010.doc	Supporting Statement B	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Repair queued
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
Consent forms.pdf	Supplementary Document	Uploaded 2010-05-27	Available
FASD_DxInt Supporting_Statement3.25.2010.doc	Supporting Statement A	Uploaded 2010-05-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193184	Lost to Follow-up	Form and Instruction	New	Form K - Dx Int Lost Follow-up
193183	Outcome Measures	Form and Instruction	New	Form J - DxInt. Outcomes J. 8-18yrs.
193183	Outcome Measures	Form and Instruction	New	Form I - DxInt. Outcomes
193182	End of Intervention/Program Customer Satisfaction	Form and Instruction	New	Form H - DxInt.CSS
193181	End of Intervention/Program Improvement Measure - Parent	Form and Instruction	New	Form G - DxInt. Improvement Measure
193180	End of Intervention/Program Improvement Measure - Case Worker	Form and Instruction	New	Form F - DxInt. Improvement Measure
193179	Services Delivery Tracking	Form and Instruction	New	Form E - DxInt.Service Tracking
193178	Services Planned and Provided	Form and Instruction	New	Form D - DxInt.Service Provided After Diag.
193177	Services Child Receiving at Time of Diagnosis	Form and Instruction	New	Form C - DxInt. Services Provided at Diag
193176	Postive Monitor Tracking	Form and Instruction	New	Form B - DxInt. Positive Monitor Tracking
193175	Screening and Diagnosis Tool	Form and Instruction	New	Form A - DxInt. Screening

ICR Details

OMB Control No: 0930-0312	ICR Reference No: 201006-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Fetal Alcohol Spectrum Disorders (FASD) Center for Excellence Diagnosis and Intervention Project
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: 08/11/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/07/2010
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2013	36 Months From Approved
Responses	19,700	0	0
Time Burden (Hours)	1,821	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of this data collection effort is to monitor the integration of the Diagnosis and Intervention projects into existing service delivery organizations. The FASD Center for Excellence will integrate the Diagnosis and Intervention projects at eight sites. A description of the intervention project and the data collection forms to be used is described below. In integrating this intervention the Center for Excellence intends to monitor and collect process level information on screening criteria used, type of FASD diagnosis, and type and amount of service provided to children. In addition improvement in performance will be measured at different time points by calculating the percent increase or decrease in a school attendance, expulsions, housing stability, and placement stability.

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Authorizing Statute(s): US Code: 5 USC 505 Name of Law: Data Collection
  

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 59190	11/17/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 29551	05/26/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 10

table that charts list of burden

IC Title	Form No.	Form Name
End of Intervention/Program Customer Satisfaction	Form H - DxInt.CSS	Form H - DxInt.CSS
End of Intervention/Program Improvement Measure - Case Worker	Form F - DxInt. Improvement Measure	Form F - DxInt. Improvement Measure
End of Intervention/Program Improvement Measure - Parent	Form G - DxInt. Improvement Measure	Form G - DxInt. Improvement Measure
Lost to Follow-up	Form K - Dx Int Lost Follow-up	Form K - Dx Int Lost Follow-up
Outcome Measures	Form I - DxInt. Outcomes, Form J - DxInt. Outcomes J. 8-18yrs.	Form I - DxInt. Outcomes ,   Form J - DxInt. Outcomes J. 8-18yrs.
Postive Monitor Tracking	Form B - DxInt. Positive Monitor Tracking	Form B - DxInt. Positive Monitor Tracking
Screening and Diagnosis Tool	Form A - DxInt. Screening	Form A - DxInt. Screening
Services Child Receiving at Time of Diagnosis	Form C - DxInt. Services Provided at Diag	Form C - DxInt. Services Provided at Diag
Services Delivery Tracking	Form E - DxInt.Service Tracking	Form E - DxInt.Service Tracking
Services Planned and Provided	Form D - DxInt.Service Provided After Diag.	Form D - DxInt.Service Provided After Diag.

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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	19,700	0	0	19,700	0	0
Annual Time Burden (Hours)	1,821	0	0	1,821	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: $1,671,931

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]? No

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: 06/07/2010

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