Monitoring of National Suicide Prevention Lifeline Form

Forms and Documents

Document Name	Status
Form CallerI Initial Sc MI/SP Caller Initial Script Form and Instruction	Modified
Form Caller Follow-up I MI/SP Caller Follow-up Interview Refusal Form and Instruction	New
Form Client Follow-up C MI/SP Caller Follow-up Consent Script Refusal Form and Instruction	New
Form CallerI Initial Sc MI/SP Caller Initial Script Refusal Form and Instruction	New
Form Follow-up Question MI/SP Counselor Follow-up Questionnaire Form and Instruction	New
Form Attitudes Question MI/SP Counselor Attitudes Questionnaire Form and Instruction	New
Form Counselor Consent MI/SP Counselor Consent Form and Instruction	New
Form Caller Follow-up I MI/SP Caller Follow-up Interview Form and Instruction	New
Form Client Follow-up C MI/SP Caller Follow-up Consent Script Form and Instruction	New
Final Hotline SS_B_07.18.13.doc Supporting Statement B	2013-07-18
Final Hotline SS_A_07.18.13.doc Supporting Statement A	2013-07-18

IC Document Collections

IC ID	Document Title	Status
7689	MI/SP Caller Initial Script Form and Instruction	Modified
207802	MI/SP Caller Follow-up Interview Refusal Form and Instruction	New
207801	MI/SP Caller Follow-up Consent Script Refusal Form and Instruction	New
207800	MI/SP Caller Initial Script Refusal Form and Instruction	New
205813	MI/SP Counselor Follow-up Questionnaire Form and Instruction	New
205812	MI/SP Counselor Attitudes Questionnaire Form and Instruction	New
205811	MI/SP Counselor Consent Form and Instruction	New
205810	MI/SP Caller Follow-up Interview Form and Instruction	New
205809	MI/SP Caller Follow-up Consent Script Form and Instruction	New

ICR Details

OMB Control No: 0930-0274	ICR Reference No: 201302-0930-001
Status: Historical Active	Previous ICR Reference No: 201208-0930-003
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 18805
Title: Monitoring of National Suicide Prevention Lifeline Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/23/2013
	Date Received in OIRA: 02/14/2013
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2016	36 Months From Approved	07/31/2013
Responses	3,131	0	3,436
Time Burden (Hours)	649	0	1,181
Cost Burden (Dollars)	0	0	0

---

Abstract: The National Suicide Prevention Lifeline--Call Monitoring Form collect information on the caller, the elements of a suicide risk assessment that are completed by the crisis worker, as well as what action plan that is developed with the caller and what referrals are provided to the caller. Additionally, the evaluation includes follow-up data collection utilizing the Crisis Hotline Telephone Follow-up Assessment. The purpose of this assessment is to collect data regarding: (1) suicide risk status at the time of and since the call, (2) depressive symptoms at follow-up, (3) service utilization since the call, (4) barriers to service access, and (5) the caller's perception of the efficacy of the hotline intervention.

---

Authorizing Statute(s): US Code: 42 USC 520A Name of Law: Priority Mental Health Needs of Regional and National Significance
  

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 73668	12/11/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 9933	02/12/2013
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 9

IC Title	Form No.	Form Name
MI/SP Caller Initial Script Refusal	CallerI Initial Script	CallerI Initial Script
MI/SP Caller Follow-up Consent Script Refusal	Client Follow-up Consent Script	Client Follow-up Consent Script
MI/SP Caller Follow-up Interview Refusal	Caller Follow-up Interview	Caller Follow-up Interview
MI/SP Caller Initial Script	CallerI Initial Script	CallerI Initial Script
MI/SP Caller Follow-up Consent Script	Client Follow-up Consent Script	Client Follow-up Consent Script
MI/SP Caller Follow-up Interview	Caller Follow-up Interview	Caller Follow-up Interview
MI/SP Counselor Consent	Counselor Consent	Counselor Consent
MI/SP Counselor Attitudes Questionnaire	Attitudes Questionnaire	Attitudes Questionnaire
MI/SP Counselor Follow-up Questionnaire	Follow-up Questionnaire	Follow-up Questionnaire

---

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	3,131	3,436	0	-305	0	0
Annual Time Burden (Hours)	649	1,181	0	-532	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: Currently there are 1,181 total burden hours in the OMB inventory. SAMHSA is requesting 646 hours. This represents a decrease of 535 hours due to a program change.

---

Annual Cost to Federal Government: $306,261

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

---

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: 02/14/2013

---