Cross-Site Evaluation of the National Child Traumatic Stress Initiative (NCTSI)

Forms and Documents

Document Name	Status
Form Baseline Core Clinical Characteristics Forms-Baseline and Follow-up Form and Instruction	Modified
Form Sustainability Sur Sustainability Survey Affiliate Centers Form and Instruction	New
Form National Reach Sur National Research Survey Form and Instruction	New
Form Training Sign-in S Training Sign-in Sheet Form and Instruction	New
Form ETSC_Providers EBP/ETSC Provider Form and Instruction	New
Form Training Summary F Training Summary Form Form and Instruction	New
Form EBP/ETSC EBP/ETSC Administrator Form and Instruction	New
Form Sustainability_Fun Sustainability Survey for Currently Funded Centers Form and Instruction	New
Form OPMR Online Performance Monitoring Report Form and Instruction	New
Form GAIN-MSS Global Appraisal of Individual Needs Modified Shore Screener Form and Instruction	New
Form CDI-2S Children Depression Inventory Form and Instruction	New
Form TSCC_A Trauma Symptoms Checklist for Children Abbreviated Form and Instruction	New
Form PSI Short Form Parenting Stress Index Form and Instruction	New
Form TSCYC Trauma Symptoms Checklist for Young Children Form and Instruction	New
Form UCLA PTSD USLA-PTSD Short Form Form and Instruction	New
Form CBCL 1.5 to 5 Core Clinical Characteristics Form Form and Instruction	New
Form Detail Form Trauma Information /Detail Form Form and Instruction	New
Core Data Set Youth Assent middle school_12-09-11.docx Supplementary Document	2011-12-09
Core Data Set Youth Assent elemen school_12-09-11.docx Supplementary Document	2011-12-09
Core Data Set Caregiver Consent_12-09-11.doc Supplementary Document	2011-12-09
NCTSI SS 9.7.11-B.doc Supporting Statement B	2011-09-07
Attachment A_B.pdf Supplementary Document	2011-09-01
Attachment J_O.pdf Supplementary Document	2011-09-01
NCTSI SS 9-6-11_rev 12-9-11.doc Supporting Statement A	2011-12-09

IC Document Collections

IC ID	Document Title	Status
7691	Core Clinical Characteristics Forms-Baseline and Follow-up Form and Instruction	Modified
199512	Sustainability Survey Affiliate Centers Form and Instruction	New
199511	National Research Survey Form and Instruction	New
199510	Training Sign-in Sheet Form and Instruction	New
199509	EBP/ETSC Provider Form and Instruction	New
199508	Training Summary Form Form and Instruction	New
199507	EBP/ETSC Administrator Form and Instruction	New
199506	Sustainability Survey for Currently Funded Centers Form and Instruction	New
199505	Online Performance Monitoring Report Form and Instruction	New
199504	Global Appraisal of Individual Needs Modified Shore Screener Form and Instruction	New
199503	Children Depression Inventory Form and Instruction	New
199502	Trauma Symptoms Checklist for Children Abbreviated Form and Instruction	New
199501	Parenting Stress Index Form and Instruction	New
199500	Trauma Symptoms Checklist for Young Children Form and Instruction	New
199499	USLA-PTSD Short Form Form and Instruction	New
199498	Core Clinical Characteristics Form Form and Instruction	New
199497	Trauma Information /Detail Form Form and Instruction	New

ICR Details

OMB Control No: 0930-0276	ICR Reference No: 201109-0930-005
Status: Historical Active	Previous ICR Reference No: 200903-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Cross-Site Evaluation of the National Child Traumatic Stress Initiative (NCTSI)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 12/11/2011
	Date Received in OIRA: 09/27/2011
Terms of Clearance: During this review, SAMHSA amended its informed consent/assent forms, specified its response rates for the CDS, and justified its incentives. OMB reviewed its draft Privacy Impact Assessment and power analysis.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2014	36 Months From Approved	07/31/2012
Responses	87,849	0	419,720
Time Burden (Hours)	22,789	0	11,333
Cost Burden (Dollars)	0	0	0

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Abstract: The NCTSI comprises of a nationwide network of grantees involved in diverse ways with improving access to care raising the standard of care for children exposed to trauma. Data is collected on information on the traumatized children's events, support they are receiving, and interventions and treatment they are receiving.

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Authorizing Statute(s): US Code: 42 USC 582 Name of Law: Grants to Address the Problems of the Persons Who Expierence Violence Related Stress
  

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 36135	06/21/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 53138	08/25/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 17

IC Title	Form No.	Form Name
USLA-PTSD Short Form	UCLA PTSD	UCLA PTSD
Trauma Symptoms Checklist for Young Children	TSCYC	TSCYC
Parenting Stress Index	PSI Short Form	PSI Short Form
Trauma Symptoms Checklist for Children Abbreviated	TSCC_A	TSCC_A
Children Depression Inventory	CDI-2S	CDI-2S
Global Appraisal of Individual Needs Modified Shore Screener	GAIN-MSS	GAIN-MSS
Online Performance Monitoring Report	OPMR	OPMR
Sustainability Survey for Currently Funded Centers	Sustainability_Funded Centers	Sustainability_Funded Centers
EBP/ETSC Administrator	EBP/ETSC	EBP/ETSC
Training Summary Form	Training Summary Form	Training Summary Form
EBP/ETSC Provider	ETSC_Providers	ETSC_Providers
Training Sign-in Sheet	Training Sign-in Sheet	Training Sign-in Sheet
National Research Survey	National Reach Survey	National Reach Survey
Sustainability Survey Affiliate Centers	Sustainability Survey	Sustainability Survey
Core Clinical Characteristics Forms-Baseline and Follow-up	Baseline, Followup	Baseline ,   Followup
Trauma Information /Detail Form	Detail Form	Detail Form
Core Clinical Characteristics Form	CBCL 6-18, CBCL 1.5 to 5	CBCL 1.5 to 5 ,   CBCL 6-18

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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	87,849	419,720	0	-331,871	0	0
Annual Time Burden (Hours)	22,789	11,333	0	11,456	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: The estimate of annual burden hours associated with the current 3-year OMB clearance period is 11,333. SAMHSA is requesting 22,789 annual hours for this submission, a program change increase of 11,456 annual burden hours.

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Annual Cost to Federal Government: $4,074,965

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: 09/27/2011

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