Web-based Skills Training for SBIRT (Screening Brief Intervention and Referral to Treatment) NIDA

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 18 Sample Copy HHS Impact Assessment	Form and Instruction	New	Available
Form 10 SP Profile	Form and Instruction	New	Available
Form 5 VSPE	Form and Instruction	New	Available
Form 2 Knowledge Test	Form and Instruction	New	Available
Form 1 Demographics	Form and Instruction	New	Available
Form 11 Eligibility Screening	Form and Instruction	New	Available
Form 9 Satistfaction Questionaire	Form and Instruction	New	Available
Form 8 SBIRT Perceived Barriers	Form and Instruction	New	Available
Form 7 SBIRT Self Efficency	Form and Instruction	New	Available
Form 6 SBIRT Attitudes	Form and Instruction	New	Available
Form 4 Clincal Practices Intentions	Form and Instruction	New	Available
Form 3 Clincal Practices Assessment	Form and Instruction	New	Available
NIDA Supporting Statement B.DOC	Supporting Statement B	Uploaded 2011-08-24	Available
Attachment 16_CertificateOfApproval-August.pdf	Supplementary Document	Uploaded 2011-08-24	Available
Attachment 17_References.doc	Supplementary Document	Uploaded 2011-08-17	Available
Attachment2_WelcomePage11.2.11.pdf	Supplementary Document	Uploaded 2011-11-29	Available
Attachment5_ReminderEmails.doc	Supplementary Document	Uploaded 2011-08-17	Available
Attachment1_RecruitmentEmail.doc	Supplementary Document	Uploaded 2011-08-17	Available
Attachment4_ConsentForm 11 2 2011.doc	Supplementary Document	Uploaded 2011-11-29	Available
Supporting Statement A Revised November 16 2011.doc	Supporting Statement A	Uploaded 2011-11-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199009	Primary Care Providers	Form and Instruction	New	Sample Copy HHS Impact Assessment
199009	Primary Care Providers	Form and Instruction	New	SP Profile
199009	Primary Care Providers	Form and Instruction	New	VSPE
199009	Primary Care Providers	Form and Instruction	New	Knowledge Test
199009	Primary Care Providers	Form and Instruction	New	Demographics
199009	Primary Care Providers	Form and Instruction	New	Eligibility Screening
199009	Primary Care Providers	Form and Instruction	New	Satistfaction Questionaire
199009	Primary Care Providers	Form and Instruction	New	SBIRT Perceived Barriers
199009	Primary Care Providers	Form and Instruction	New	SBIRT Self Efficency
199009	Primary Care Providers	Form and Instruction	New	SBIRT Attitudes
199009	Primary Care Providers	Form and Instruction	New	Clincal Practices Intentions
199009	Primary Care Providers	Form and Instruction	New	Clincal Practices Assessment

ICR Details

OMB Control No: 0925-0646	ICR Reference No: 201108-0925-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No:
Title: Web-based Skills Training for SBIRT (Screening Brief Intervention and Referral to Treatment) NIDA
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 with change	Conclusion Date: 12/12/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/25/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2013	10/31/2013
Responses	94	0	0
Time Burden (Hours)	188	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goal of the contract is to design, develop and evaluate a web-based training (WBT) program to teach screening and brief intervention for substance use problems (SBIRT) to primary care physicians (PCPs). The WBT will be designed to train PCPs to screen, intervene, and refer for substance problems and to support the use and maintenance of those skills with reference guides, screening tools and location-specific referral databases. Phase I work included a) needs assessment; b) designing instructional and web design strategies for the training; c) outlining content for the WBT, including selecting screening tools and a model for brief intervention; d) developing a prototype; and e) eliciting feedback on the prototype via usability testing and expert review. The Phase II work will include full development of the WBT, accreditation of the course for CME, and evaluation of the WBT in a randomized educational effectiveness trial. For the randomized trial, ninety-four primary care providers will be recruited and randomized to use either the WBT or a reading materials training covering similar content. Outcome measures will include standardized patient interviews, knowledge tests and user acceptance and satisfaction. The final product will be licensed to healthcare organizations and customizable to their specific needs.

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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:
	76 FR 30177	05/24/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 50233	08/12/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Primary Care Providers	3, 4, 6, 7, 8, 9, 11, 2, 5, 10, 18, 1	Clincal Practices Assessment ,   Clincal Practices Intentions ,   SBIRT Attitudes ,   SBIRT Self Efficency ,   SBIRT Perceived Barriers ,   Satistfaction Questionaire ,   Eligibility Screening ,   Demographics ,   Knowledge Test ,   VSPE ,   SP Profile ,   Sample Copy HHS Impact Assessment

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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	94	0	0	94	0	0
Annual Time Burden (Hours)	188	0	0	188	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 ICR.

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Annual Cost to Federal Government: $379,471

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: 08/25/2011

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