Minority Substance Abuse/HIV Prevention Initiative

Forms and Documents

Document Name	Status
Form Youth Questionnair Youth Form	New
Form Adult Questionnair Adult Form	Modified
HIV Sample Consent Form.docx Supplementary Document	2012-09-24
HIV OMB SS-B 1-24-13.docx Supporting Statement B	2013-01-24
HIV Youth Admin Guide 120321_Cleaned.docx Supplementary Document	2012-07-16
HIV Adult Admin Guide 120321_Cleaned.docx Supplementary Document	2012-07-16
HIVOverarching Guide Cohort N.docx Supplementary Document	2012-07-16
HIV OMB SS-A 1-24-13.docx Supporting Statement A	2013-01-24

IC Document Collections

IC ID	Document Title	Status
203550	Youth Form	New
187120	Adult Form	Modified

ICR Details

OMB Control No: 0930-0298	ICR Reference No: 201208-0930-001
Status: Historical Active	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: Reinstatement with change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/10/2013
	Date Received in OIRA: 08/01/2012
Terms of Clearance: As shown by the changes made to this collection, SAMHSA shall correctly enter its burden information in ROCIS. In addition, SAMHSA shall continue to address issues associated with respondent selection, response verification, and incentive use.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved
Responses	20,512	0	0
Time Burden (Hours)	15,049	0	0
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 516 Name of Law: Priority Substance Abuse Prevention Needs of Reginional 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:
	77 FR 29355	05/17/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 41794	07/16/2012
Did the Agency receive public comments on this ICR? No

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

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

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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	20,512	0	0	20,512	0	0
Annual Time Burden (Hours)	15,049	0	0	15,049	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 reinstatement.

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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: 08/01/2012

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