Minority Substance Abuse/HIV Prevention Initiative

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Adult Questionniar Adult Questionnaire	Form	Modified	Available
SS-HIV 9.20.11- B.doc	Supporting Statement B	Uploaded 2011-09-29	Available
Overview of Instruments Guide.docx	Supplementary Document	Uploaded 2011-09-29	Available
SS-HIV 9.20.11- A.doc	Supporting Statement A	Uploaded 2011-09-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
199787	Youth Questionnaire	Instruction	New
187120	Adult Questionnaire	Form	Modified

ICR Details

OMB Control No: 0930-0298	ICR Reference No: 201110-0930-002
Status: Historical Inactive	Previous ICR Reference No: 200811-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Minority Substance Abuse/HIV Prevention Initiative
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Withdrawn and continue	Conclusion Date: 02/13/2012
	Date Received in OIRA: 10/19/2011
Terms of Clearance: This collection was withdrawn at the request of SAMHSA. If SAMHSA chooses to re-submit this collection, the agency shall submit an accurate estimate of respondents and burden hours in its 60-day notice and 30-day notice. SAMHSA shall submit the following materials for this ICR: 1. Informed consent materials (if these vary by grantee, SAMHSA shall provide an exemplar with information common across consents included); 2. Privacy Impact Assessment 3. Description of incentives offered by grantees for this federally funded and directed information collection. Form and dollar value should be provided, including an estimation of participants who would not be offered any incentives. 4. Citation of privacy statute in consent material and in the supporting statements. Length of interview should be clarified for participant, assuming bimodal distribution of length given skip pattern use. At the time of a potential resubmission, assuming the materials listed above are provided, the agency must address the following issues to receive a three-year clearance: 1. Unclear sampling plan (whether census, probability sample, or purposeful sample) 2. Unclear means to address nonresponse bias 3. Unclear analysis plan and analysis of prior collections (which would inform the current proposal)

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2012	36 Months From Approved	03/31/2012
Responses	20,205	0	20,205
Time Burden (Hours)	16,770	0	16,770
Cost Burden (Dollars)	0	0	0

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Abstract: The Youth and Adult Minority Substance Abuse Questionnaires will be used to survey populations at risk for Substance Abuse, HIV/AIDS, and hepatitis. The participants are those in the Program who receive direct services for over 30 days at three time points: (1) baseline (program entry), (2) program exit, and (3) three to six months post-exit.

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Authorizing Statute(s): US Code: 42 USC 290bb-22 Name of Law: Priority Substance Abuse Prevention Needs of Regional and National Significance
  

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 44942	07/27/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 61108	10/03/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Adult Questionnaire	Adult Questionniare	Adult Questionniare
Youth Questionnaire	Youth Questionnaire	Youth Questionnaire

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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 16,770 hours in the OMB inventory. CSAP is requesting 14,844. The decrease of 1,926 hours is due to an adjustment. The original estimate was based on all participants being enrolled in 30-day or longer interventions. The current adjustment also accounts for interventions lasting less than 30 days.

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Annual Cost to Federal Government: $710,806

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: 10/19/2011

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