Enhancing Substance Abuse Treatment Services to Address Hepatitis Infection Among Intravenous Drug Users Hepatitis Testing and Vaccine Tracking Form

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Hepatitis Reportin SAMHSA/CSAT's Viral Hepatitis Information Form	Form	Modified	Available
0300-SS 3-18-13.docx	Supporting Statement A	Uploaded 2013-03-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
188545	SAMHSA/CSAT's Viral Hepatitis Information Form	Form	Modified

ICR Details

OMB Control No: 0930-0300	ICR Reference No: 201212-0930-001
Status: Historical Active	Previous ICR Reference No: 200903-0930-003
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Enhancing Substance Abuse Treatment Services to Address Hepatitis Infection Among Intravenous Drug Users Hepatitis Testing and Vaccine Tracking Form
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: 03/20/2013
	Date Received in OIRA: 12/13/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2016	36 Months From Approved
Responses	800	0	0
Time Burden (Hours)	40	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The information collected on the Form will solicit and reflect the following information: 1)Demographics (age, gender, ethnicity) of designated OTP site 2)History (Screening) of Hepatitis C exposure 3)Results of Rapid Hepatitis C Testing (Kit) and Follow-up information 4)Service Provided (type of vaccine given) Divalent vaccine (Twinrix- combination HAV and HBV) or Monovalent vaccine ( HAV or/and HBV) 5)Substance Abuse Treatment Outcomes (Information regarding the beginning, continuing or completion of vaccination series) 6)Type of Referral Services Indicated (ie; Gastroenterology, TB; Mental Health, Counseling, Reproductive/Prenatal, etc.)

---

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

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 24211	04/23/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 37912	06/25/2012
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
SAMHSA/CSAT's Viral Hepatitis Information Form	Hepatitis Reporting Form, Hepatitis Reporting Form	Hepatitis Reporting Form

---

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	800	0	0	800	0	0
Annual Time Burden (Hours)	40	0	0	40	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 a reinstatement.

---

Annual Cost to Federal Government: $93,000

Does this IC contain surveys, censuses, or employ statistical methods? No

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

---

Common Form ICR:  No

---

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: 12/13/2012

---