Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form G. Coalition Surve G. Coalition Survey Instrument and Web Consent.docx	Form and Instruction	New	Available
Form E. RNS Instrument E. RNS Instrument and Verbal Consent Script.docx	Form and Instruction	New	Available
Form D8. TUP-S-A Consen D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx	Form and Instruction	New	Available
Form D7.Training Utiliz D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx	Form and Instruction	New	Available
Form Campus Staff Instr Campus Staff Instruments	Form and Instruction	Removed	Available
Form Student Instrument Student Instruments	Form and Instruction	Removed	Available
Form Campus--Provider ( Campus--Provider (Trainees) Instruments	Form and Instruction	Modified	Available
Form Campus Staff Instr Campus Staff Instruments	Form and Instruction	Removed	Available
Form I3. LAFI Verbal Co I3. LAFI Verbal Consent Script.doc	Form and Instruction	Modified	Available
Form I1. LAFI Instrumen I1. LAFI Instrument.doc	Form and Instruction	Modified	Available
Form D6. TUP-S Campus V D6. TUP-S Campus Verbal Consent.doc	Form and Instruction	Modified	Available
Form D5. TUP-S Campus C D5. TUP-S Campus Consent-to-Contact Form.docx	Form and Instruction	Modified	Available
Form J.2 SAIS Follow-up J.2 SAIS Follow-up Instrument and Web Consent.docx	Form and Instruction	Modified	Available
Form J.1 SAIS Baseline J.1 SAIS Baseline Instrument and Web Consent.docx	Form and Instruction	Modified	Available
Form I2. LAFI Consent t I2. LAFI Consent to Contact Form.doc	Form and Instruction	Modified	Available
Form Campus-Project Eva Campus-Project Evaluator Instruments	Form and Instruction	Modified	Available
Form D9. TUP-S-6 Month D9. TUP-S-6 Month Instrument and Verbal Consent	Form and Instruction	Modified	Available
Form D2. Training Utili D2. Training Utilization and Preservation Survey	Form and Instruction	Modified	Available
Form D3 TUP-S Verbal Co D3 TUP-S Verbal Consent Script	Form and Instruction	Modified	Available
Form H1. EIRF Analysis H1. EIRF Analysis Form (EIRF)	Form and Instruction	Modified	Repair queued
Appendix A - IRB Findings Form.pdf	Supplementary Document	Uploaded 2014-01-08	Available
HSDW PIA form GLS OMB 112513.docx	Supplementary Document	Uploaded 2014-01-08	Available
0286-SS-B-1.8.14.docx	Supporting Statement B	Uploaded 2014-01-08	Available
A14 CCS - Campus Staff Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-03	Available
A12 CCS - Student Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-03	Available
A9 Campus - Staff Supporting Documents.pdf	Supplementary Document	Uploaded 2010-06-02	Available
Project Evaluator--StateTribal & Campus Other Documents.pdf	Supplementary Document	Uploaded 2013-08-17	Available
Project Evaluator--StateTribal & Campus Other Documents.pdf	Supplementary Document	Uploaded 2013-08-17	Available
0286-SS-A-1.8.14.docx	Supporting Statement A	Uploaded 2014-01-08	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208304	Provider - State/Tribal - Stakeholder	Form and Instruction	New	G. Coalition Survey Instrument and Web Consent.docx
208304	Provider - State/Tribal - Stakeholder	Form and Instruction	New	E. RNS Instrument and Verbal Consent Script.docx
208303	Adolescents - State/Tribal - Trainees	Form and Instruction	New	D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx
208303	Adolescents - State/Tribal - Trainees	Form and Instruction	New	D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx
193190	Campus Staff - Campus Case	Form and Instruction	Removed	Campus Staff Instruments
178438	Student - Campus Case	Form and Instruction	Removed	Student Instruments
178437	Providers - Campus - Trainees	Form and Instruction	Modified	Campus--Provider (Trainees) Instruments
178436	Campus Staff - Campus	Form and Instruction	Removed	Campus Staff Instruments
178435	Student - Campus	Form and Instruction	Modified	I3. LAFI Verbal Consent Script.doc
178435	Student - Campus	Form and Instruction	Modified	I1. LAFI Instrument.doc
178435	Student - Campus	Form and Instruction	Modified	D6. TUP-S Campus Verbal Consent.doc
178435	Student - Campus	Form and Instruction	Modified	D5. TUP-S Campus Consent-to-Contact Form.docx
178435	Student - Campus	Form and Instruction	Modified	J.2 SAIS Follow-up Instrument and Web Consent.docx
178435	Student - Campus	Form and Instruction	Modified	J.1 SAIS Baseline Instrument and Web Consent.docx
178435	Student - Campus	Form and Instruction	Modified	I2. LAFI Consent to Contact Form.doc
178434	Project Evaluators - Campus	Form and Instruction	Modified	Campus-Project Evaluator Instruments
178433	Providers - State/Tribal - Trainees	Form and Instruction	Modified	D9. TUP-S-6 Month Instrument and Verbal Consent
178433	Providers - State/Tribal - Trainees	Form and Instruction	Modified	D2. Training Utilization and Preservation Survey
178433	Providers - State/Tribal - Trainees	Form and Instruction	Modified	D3 TUP-S Verbal Consent Script
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	H1. EIRF Analysis Form (EIRF)

ICR Details

OMB Control No: 0930-0286	ICR Reference No: 201308-0930-001
Status: Historical Active	Previous ICR Reference No: 201006-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 20339
Title: Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program
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: 01/09/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 08/20/2013
Terms of Clearance: SAMHSA shall continue to examine ways to minimize burden on the respondent population.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	36 Months From Approved	01/31/2014
Responses	20,347	0	445,272
Time Burden (Hours)	8,014	0	26,444
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected through the four stages of the cross-site evaluation of the GLS Suicide Prevention and Early Intervention Programs will describe for State/Tribal grantees (1) the context in which suicide prevention activities are being implemented, (2) the products and services funded through the program, (3) the training experiences of individuals who receive training as part of the suicide prevention programs, (4) the utilization and penetration of the skills, knowledge and techniques learned through suicide prevention training programs, and (5) the referral networks in place to support youth identified at risk for suicide.

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Authorizing Statute(s): US Code: 42 USC 520E-2 Name of Law: Mental and Bhavioral Health Services on Campus
  

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:
	78 FR 36205	04/17/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 50070	08/16/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Adolescents - State/Tribal - Trainees	D7.Training Utilization and Preservation Survey , D8. TUP-S-A Consent-to-Contact	D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx ,   D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx
Campus Staff - Campus	Campus Staff Instruments	Campus Staff Instruments
Campus Staff - Campus Case	Campus Staff Instruments	Campus Staff Instruments
Project Evaluators - Campus	Campus-Project Evaluator Instruments	Campus-Project Evaluator Instruments
Project Evaluators - State/Tribal	H1. EIRF Analysis Form (EIRF)	H1. EIRF Analysis Form (EIRF)
Provider - State/Tribal - Stakeholder	E. RNS Instrument and Verbal Consent Script.docx, G. Coalition Survey Instrument and Web Consent	E. RNS Instrument and Verbal Consent Script.docx ,   G. Coalition Survey Instrument and Web Consent.docx
Providers - Campus - Trainees	Campus--Provider (Trainees) Instruments	Campus--Provider (Trainees) Instruments
Providers - State/Tribal - Trainees	D3 TUP-S Verbal Consent Script, D2. Training Utilization and Preservation Survey, D9. TUP-S-6 Month Instrument and Verbal Consent	D3 TUP-S Verbal Consent Script ,   D2. Training Utilization and Preservation Survey ,   D9. TUP-S-6 Month Instrument and Verbal Consent
Student - Campus	I2. LAFI Consent to Contact Form.doc, J.1 SAIS Baseline Instrument and Web Consent.docx, J.2 SAIS Follow-up Instrument and Web Consent.docx, D5. TUP-S Campus Consent-to-Contact Form.docx, D6. TUP-S Campus Verbal Consent.doc, I1. LAFI Instrument.doc, I3. LAFI Verbal Consent Script.doc	J.1 SAIS Baseline Instrument and Web Consent.docx ,   J.2 SAIS Follow-up Instrument and Web Consent.docx ,   D5. TUP-S Campus Consent-to-Contact Form.docx ,   D6. TUP-S Campus Verbal Consent.doc ,   I1. LAFI Instrument.doc ,   I3. LAFI Verbal Consent Script.doc ,   I2. LAFI Consent to Contact Form.doc
Student - Campus Case	Student Instruments	Student Instruments

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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	20,347	445,272	0	-38,356	-386,569	0
Annual Time Burden (Hours)	8,014	26,444	0	-2,688	-15,742	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 26,444 burden hours in the OMB inventory. SAMHSA is requesting 8,014 hours for this submission. This represents a decrease in burden of 18,430 hours. The number of grantees for which burden is calculated is 121 (61 State/Tribal grantees and 60 Campus grantees), which represents the number of currently active grantees.

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Annual Cost to Federal Government: $4,092,003

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: 08/20/2013

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