Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Campus Staff Instr Campus Staff Instruments	Form and Instruction	New	Available
Form Student Instrument Student Instruments	Form and Instruction	Modified	Repair queued
Form Campus - Providers Campus - Providers Instruments	Form and Instruction	Modified	Available
Form Campus Staff Instr Campus Staff Instruments	Form and Instruction	Modified	Available
Form Campus - Student I Campus - Student Instruments	Form and Instruction	Modified	Available
Form Campus - Project E Campus - Project Evaluators Insturments	Form and Instruction	Modified	Available
Form Provider Instrumen Provider Instruments	Form and Instruction	Modified	Available
Form Project Evaluators Project Evaluators Instruments	Form and Instruction	Modified	Available
Suicide Cross-Site-Eval Supporting Statement V 6 (FINAL_672010).doc	Supporting Statement B	Uploaded 2010-06-07	Available
A14 CCS - Campus Staff Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-03	Available
A12 CCS - Student Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-03	Available
A9 Campus - Staff Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-02	Available
A7 Campus - Student Suporting Documents.pdf	Supplementary Document	Uploaded 2010-06-02	Available
A4 ST - Provider Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-02	Available
A2 ST - Project Evaluator Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-02	Available
Suicide Cross-Site-Eval Supporting Statement V 6 (FINAL_672010).doc	Supporting Statement A	Uploaded 2010-06-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
193190	Campus Staff - Campus Case	Form and Instruction	New	Campus Staff Instruments
178438	Student - Campus Case	Form and Instruction	Modified	Student Instruments
178437	Providers - Campus	Form and Instruction	Modified	Campus - Providers Instruments
178436	Campus Staff - Campus	Form and Instruction	Modified	Campus Staff Instruments
178435	Student - Campus	Form and Instruction	Modified	Campus - Student Instruments
178434	Project Evaluators - Campus	Form and Instruction	Modified	Campus - Project Evaluators Insturments
178433	Providers - State/Tribal	Form and Instruction	Modified	Provider Instruments
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	Project Evaluators Instruments

ICR Details

OMB Control No: 0930-0286	ICR Reference No: 201006-0930-002
Status: Historical Active	Previous ICR Reference No: 200701-0930-005
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/03/2010
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/08/2010
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	08/31/2010
Responses	445,272	0	26,229
Time Burden (Hours)	26,444	0	6,331
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected through the four stages of the cross-site evaluation of the GLS Suicide Prevention and Early Intervention Programs will describe for State/Tribal grantees (1) the context in which suicide prevention activities are being implemented, (2) the products and services funded through the program, (3) the training experiences of individuals who receive training as part of the suicide prevention programs, (4) the utilization and penetration of the skills, knowledge and techniques learned through suicide prevention training programs, and (5) the referral networks in place to support youth identified at risk for suicide.

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Authorizing Statute(s): None

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:
	75 FR 7600	02/22/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 30833	06/02/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Campus Staff - Campus	Campus Staff Instruments	Campus Staff Instruments
Campus Staff - Campus Case	Campus Staff Instruments	Campus Staff Instruments
Project Evaluators - Campus	Campus - Project Evaluators Insturments	Campus - Project Evaluators Insturments
Project Evaluators - State/Tribal	Project Evaluators Instruments	Project Evaluators Instruments
Providers - Campus	Campus - Providers Instruments	Campus - Providers Instruments
Providers - State/Tribal	Provider Instruments	Provider Instruments
Student - Campus	Campus - Student Instruments	Campus - Student Instruments
Student - Campus Case	Student Instruments	Student Instruments

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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	445,272	26,229	0	419,043	0	0
Annual Time Burden (Hours)	26,444	6,331	0	20,113	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Currently there are 6,331 total burden hours in the OMB inventory. SAMHSA is requesting 26,444 hours for this submission. This represents an increase in burden of 20,113 hours due to a program change. The number of grantees for which burden is calculated is 86 (48 State/Tribal grantees and 38 Campus grantees), which represents the number of currently active grantees and is close to the 91 grantees (36 State/Tribal grantees and 55 Campus grantees).

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Annual Cost to Federal Government: $3,583,452

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: 06/08/2010

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