Evaluation of SAMHSA Primary Care Behavioral Health Integration Grant Program

Forms and Documents

Document Name	Status
OMB Supporting Statment Part B 6 mos final 2 11 11.doc Supporting Statement B	2011-02-15
0990-PBHCI Attach 18 RAND IRB APPLICATION 1 14 11.pdf Supplementary Document	2011-01-25
0990-PBHCI Attach 16 Telephone Script.doc Supplementary Document	2011-01-25
0990-PBHCI Attach 15 Baseline Client Consent-Controls.doc Supplementary Document	2011-01-25
0990-PBHCI Attach 14 Baseline Client Consent.doc Supplementary Document	2011-01-25
0990-PBHCI Attach 13 Initial contact letter.doc Supplementary Document	2011-01-25
0990-PBHCI Attach 12 Consent Protocol Site Visit Interviews-Controls.doc Supplementary Document	2011-01-25
0990-PBHCI Attach 11 Consent Protocol Site Visit Interviews.doc Supplementary Document	2011-01-25
OMB Supporting Statement Part A 6 mos pkg final 2 11 11.doc Supporting Statement A	2011-02-15

IC Document Collections

IC ID	Document Title	Status
196137	Site Project Director (quarterly report) Other-REPORT	New
196136	Site data collection personnel (client-level service utilization report) Other-REPORT	New
196135	Site data entry personnel (PH indicators into TRAC) Other-TRAC	New
196134	Key staff interview (control sites) Other-interview	New
196133	Care coordinators interivew Other-interview	New
196132	MH Provider Interview Other-interview	New
196131	PCP provider interview Other-interview	New
196130	Site Leadership interview (intervention sites) Other-interview	New
196129	Consumers with SMI at control sites Other-questions	New

ICR Details

OMB Control No: 0990-0371	ICR Reference No: 201102-0990-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/HHSDM	Agency Tracking No:
Title: Evaluation of SAMHSA Primary Care Behavioral Health Integration Grant Program
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Emergency	Approval Requested By: 02/05/2011
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/15/2011
	Date Received in OIRA: 02/04/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2011	6 Months From Approved
Responses	13,440	0	0
Time Burden (Hours)	4,211	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: SAMHSA's PBHCI grantees have been developing and implementing an array of integrated services designed to improve the physical and behavioral health status of people with serious mental illnesses, including individuals with co-occurring substance use disorders. These services incorporate a prevention and wellness approach and are provided using different models of cooperation and collaboration between community behavioral health and primary care.

Emergency Justfication: The approval of this request through the emergency clearance process is essential in order to begin the data collection activities in a timely manner. A delay in this process will negatively affect the evaluation of the program and increase contractual costs associated with the evaluation.

---

Authorizing Statute(s): US Code: 38 USC 527 Name of Law: Evaluation and Data Collection
   PL: Pub.L. 103 - 62 527 Name of Law: Government Performance and Results Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
Consumers with SMI at control sites
Site Leadership interview (intervention sites)
PCP provider interview
MH Provider Interview
Care coordinators interivew
Key staff interview (control sites)
Site data entry personnel (PH indicators into TRAC)
Site data collection personnel (client-level service utilization report)
Site Project Director (quarterly report)

---

ICR Summary 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	13,440	0	0	13,440	0	0
Annual Time Burden (Hours)	4,211	0	0	4,211	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 collection.

---

Annual Cost to Federal Government: $242,961

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]? Yes

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)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 02/04/2011

---