Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Individual Family Encounter Form	Form and Instruction	Modified	Available
Service Provider Feedback Form	Form and Instruction	New	Available
Participant Feedback Form	Form and Instruction	New	Available
Child Youth Assessment and Referral Tool	Form and Instruction	New	Available
Adult Assessment and Referral tool	Form and Instruction	New	Available
Weekly Tally Sheet	Form and Instruction	New	Available
Group Encounter Log	Form and Instruction	New	Available
Attach F Letterfrom Norris and Brymer CCP Assessment and Referral Tools - 2 1612.doc	Supplementary Document	Uploaded 2012-08-07	Available
Attach G Email from SAMHSA CMHS Chief Suicide Prevention Branch.docx	Supplementary Document	Uploaded 2012-08-07	Available
Attach H Email from NSPL Suicide LifeLine Use of Paraprofessional CCP Assessment and Referral Tools.docx	Supplementary Document	Uploaded 2012-08-07	Available
NB Part B OMB CCP Revised Supporting Statement 7 31 12.docx	Supporting Statement B	Uploaded 2012-08-07	Available
Attachment H Public Comments Received.docx	Supplementary Document	Uploaded 2012-02-17	Available
Attachment I_Response to CommentsFINAL.docx	Supplementary Document	Uploaded 2012-02-17	Available
NB Part A OMB CCP Revised Supporting Statement 7 31 12.docx	Supporting Statement A	Uploaded 2012-08-07	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form and Instruction	Modified	Individual Family Encounter Form
201612	Service Provider Feedback Form	Form and Instruction	New	Service Provider Feedback Form
201611	Particpant Feedback Form	Form and Instruction	New	Participant Feedback Form
201610	Asessment and Referral Tool	Form and Instruction	New	Child Youth Assessment and Referral Tool
201610	Asessment and Referral Tool	Form and Instruction	New	Adult Assessment and Referral tool
201609	Weekly Tally Sheet	Form and Instruction	New	Weekly Tally Sheet
201608	Group Encounter Log	Form and Instruction	New	Group Encounter Log

ICR Details

OMB Control No: 0930-0270	ICR Reference No: 201203-0930-002
Status: Historical Active	Previous ICR Reference No: 200809-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)
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: 08/17/2012
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/20/2012
Terms of Clearance: As shown by the changes made to this collection, SAMHSA shall continue verify its burden estimates are accurate and consistent throughout the submission. SAMHSA shall insert the correct OMB control number (0930-0270) on all instruments.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2015	36 Months From Approved	08/31/2012
Responses	53,000	0	128,400
Time Burden (Hours)	7,622	0	12,297
Cost Burden (Dollars)	0	0	0

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Abstract: Data collection about services delivered and users of the services will be collected from the CCPs through standardized information tools which will then be reported to SAMHSA for appropriate processing and analysis. CCPs will be required to use the tools for data collection throughout the life of the program.

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Authorizing Statute(s): US Code: 42 USC 501 Name of Law: SAMHSA
  

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 71351	11/17/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 9679	02/17/2012
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Asessment and Referral Tool	N/A, N/A	Adult Assessment and Referral tool ,   Child Youth Assessment and Referral Tool
Group Encounter Log	N/A	Group Encounter Log
Individual/Family Crisis Counseling Servies Encounter Log	N/A	Individual Family Encounter Form
Particpant Feedback Form	N/A	Participant Feedback Form
Service Provider Feedback Form	N/A	Service Provider Feedback Form
Weekly Tally Sheet	N/A	Weekly Tally Sheet

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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	53,000	128,400	0	-75,400	0	0
Annual Time Burden (Hours)	7,622	12,297	0	-4,675	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 current burden estimate is 12,297 hours. SAMHSA CMHS is requesting a decrease in burden to 7,662 total burden hours. This adjustment is mainly due to the updated utilization rates of the Individual/Family Encounter Log, Group Encounter Log, and Assessment and Referral Tools, in addition to the reduction of forms needed to be completed due to the combined Individual/Family Encounter Log (see Item 12 of this supporting statement). Additional time is required to complete the two additional fields in the Weekly Tally Sheet.

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Annual Cost to Federal Government: $59,619

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: 03/19/2012

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