Site Visits With Grantees Integrated HIV Primary Care, Sustance Abuse, and Behavioral Health Services

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Site Visits Year O Assessment Form	Form and Instruction	New	Available
Form Site Visits Year O Interview Guide	Form and Instruction	New	Available
OMB Supp Statement-B-06.5.13 Final.doc	Supporting Statement B	Uploaded 2013-06-05	Available
Public Burden Statement.doc	Supplementary Document	Uploaded 2012-12-19	Available
Public Burden Statement.doc	Supplementary Document	Uploaded 2012-12-19	Available
OMB Supp Statement-A-06.5.13 Final.doc	Supporting Statement A	Uploaded 2013-06-05	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205169	Assessment Form	Form and Instruction	New
205168	Interview Guide	Form and Instruction	New

ICR Details

OMB Control No: 0930-0336	ICR Reference No: 201212-0930-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Site Visits With Grantees Integrated HIV Primary Care, Sustance Abuse, and Behavioral Health Services
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 06/20/2013
	Date Received in OIRA: 12/20/2012
Terms of Clearance: Within 6 weeks of approval, SAMHSA has agreed to provide OMB with a document specifying the differences and overlaps between this information collection and CDC's information collections concerning HIV.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2016	36 Months From Approved
Responses	110	0	0
Time Burden (Hours)	156	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The goals of the MAI-TCE project are to facilitate the development and expansion of culturally competent and effective integrated behavioral health and primary care, which include HIV services and medical treatment within 11 of the 12 Metropolitan Statistical Areas (MSAs) and Metropolitan Divisions (MDs) most heavily impacted by HIV/AIDS. The program also supports the integration of behavioral health services (i.e., prevention, treatment, and substance abuse) into the CDC's Enhanced Comprehensive HIV Prevention Plans (ECHPP). Interviews conducted with MAI-TCE grantees during site visits are an integral part of efforts to evaluate: (1) the effectiveness of program implementation across the grantee sites; (2) grantee efforts to integrate behavioral health, substance abuse and HIV care; (3) the variety of program models in use across the grantee sites; and, (4) grantee efforts to engage and successfully reach their target populations.

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Authorizing Statute(s): None

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 59626	09/28/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 75181	12/19/2012
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
Interview Guide	Site Visits Year One Site Visit Interview Guide	Site Visits Year One Site Visit Interview Guide
Assessment Form	Site Visits Year One Site Visit Form	Site Visits Year One Site Visit Form

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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	110	0	0	110	0	0
Annual Time Burden (Hours)	156	0	0	156	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 new data collection.

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Annual Cost to Federal Government: $58,670

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: 12/20/2012

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