The Safe School/Healthy Student (SS/HS) Initiative National Evaluation

Forms and Documents

Document Name	Status
Form Site Visit Protoco Site Visit Protocol Form and Instruction	New
Form Baseline Assessmen Baseline Assessment Survey Form and Instruction	New
Form Partnership Invent Partnership Inventory Form and Instruction	New
Form Project-Level Surv Project Level Survey Form and Instruction	New
Form School-Level Surve School Level Survey Form and Instruction	New
Form Staff School Clima Staff School Climate Survey Form and Instruction	Modified
Supporting Statement-B.doc Supporting Statement B	2011-08-11
8. Sample Emails for Instruments.pdf Supplementary Document	2011-08-11
1. SSHS Introduction letter.doc Supplementary Document	2011-08-11
9. GPRA Student Survey.doc Supplementary Document	2011-08-11
Supporting Statement-A.doc Supporting Statement A	2011-09-20

IC Document Collections

IC ID	Document Title	Status
199378	Site Visit Protocol Form and Instruction	New
199377	Baseline Assessment Survey Form and Instruction	New
199376	Partnership Inventory Form and Instruction	New
199375	Project Level Survey Form and Instruction	New
199374	School Level Survey Form and Instruction	New
184514	Staff School Climate Survey Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0297	ICR Reference No: 201109-0930-002
Status: Historical Active	Previous ICR Reference No: 200804-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: The Safe School/Healthy Student (SS/HS) Initiative National Evaluation
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: 11/18/2011
	Date Received in OIRA: 09/21/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	11/30/2014	36 Months From Approved	01/31/2012
Responses	28,125	0	106,675
Time Burden (Hours)	4,973	0	16,431
Cost Burden (Dollars)	0	0	0

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Abstract: The three Federal agencies collaborating on the Initiative share an expectation that LEAs and communities nationwide will benefit from the documented experiences of the grantees. A letter to introduce the National Evaluation Team (NET) was mailed to all grantees from the Director of the Division of Prevention, Traumatic Stress and Special Programs at SAMHSA. The NET has developed instruments to collect detailed quantitative and qualitative data on the grant activities and the local collaborative process. These instruments all apply to the local Project Director of the grant, the local project evaluator, one representative of each local organization that formally partners in the administration of the grant activities, one representative of each school receiving services through this grant, and instructional and administrative staff at targeted schools.

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Authorizing Statute(s): US Code: 42 USC 290hh Name of Law: Children and Violence
  

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 28238	05/16/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44340	07/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Staff School Climate Survey	Staff School Climate Survey	Staff School Climate Survey
School Level Survey	School-Level Survey	School-Level Survey
Project Level Survey	Project-Level Survey	Project-Level Survey
Partnership Inventory	Partnership Inventory	Partnership Inventory
Baseline Assessment Survey	Baseline Assessment	Baseline Assessment
Site Visit Protocol	Site Visit Protocol	Site Visit Protocol

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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	28,125	106,675	0	-78,550	0	0
Annual Time Burden (Hours)	4,973	16,431	0	-11,458	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 16,431 hours in the OMB inventory. The Program is requesting 4,973 hours. The program change in burden is due to a decrease in the number of respondent that are being requested to complete the Staff School Climate Survey (106,675 to 25,200).

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Annual Cost to Federal Government: $1,435,035

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: 09/21/2011

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