Participant Feedback Forms for the Mental Health Care Provider Education (MHCPE) in the HIV/AIDS Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
CMHS MHCPE Supporting Statement Final 3 17 2011(2).docx	Supporting Statement B	Uploaded 2011-03-18	Available
CMHS MHCPE Supporting Statement Final 3 17 2011(2).docx	Supporting Statement A	Uploaded 2011-03-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7583	Session Report Form	Instruction	Modified
195853	Ethics Participant Feedback Form	Instruction	New
195852	Adherence Participant Feedback Form	Instruction	New
195851	Neuropsychiatric Participant Feedback	Instruction	New
195850	Participant Feedback Form	Instruction	New

ICR Details

OMB Control No: 0930-0195	ICR Reference No: 201012-0930-001
Status: Historical Active	Previous ICR Reference No: 200711-0930-003
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Participant Feedback Forms for the Mental Health Care Provider Education (MHCPE) in the HIV/AIDS Program
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/18/2011
	Date Received in OIRA: 12/30/2010
Terms of Clearance: The agency will not collect social security numbers or partial social security numbers as part of this collection.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved	03/31/2011
Responses	12,600	0	12,600
Time Burden (Hours)	1,843	0	1,843
Cost Burden (Dollars)	0	0	0

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Abstract: These standardized forms will collect systematic feedback from trainees participating in the Minority HIV/AIDS Mental Health Treatment and Education Services Program and the Mental Health Care Provider Education in HIV/AIDS III Program. The overall goal of the two programs is to help create a cadre of traditional and non-traditional mental health service providers who utilize state-of-the-art information on the psychological and neuropsychological sequelae of HIV/AIDS, and to enhance the nation's ability to have an impact on the HIV/AIDS epidemic.

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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:
	75 FR 35819	06/23/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 79011	12/17/2010
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Neuropsychiatric Participant Feedback	Neuropsychiatric Participant Feedback	Neuropsychiatric Participant Feedback
Adherence Participant Feedback Form	Adherence Participant Feedback	Adherence Participant Feedback
Ethics Participant Feedback Form	Ethics Participant Feedback Form	Ethics Participant Feedback Form
Session Report Form	Session Report Form, Session Report Form	Session Report Form
Participant Feedback Form	Participant Feedback Form	Participant Feedback Form

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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	12,600	12,600	0	0	0	0
Annual Time Burden (Hours)	1,843	1,843	0	0	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: No change in burden is being requested. The numbers had to be adjusted in the system to go from one IC to 5 ICs.

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Annual Cost to Federal Government: $395,000

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]? No

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: 12/30/2010

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