SAMHSA Tobacco Prevention, Cessation, and Behavioral Health Message Testing

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Health Care Profes Provider Interview	Form and Instruction	New	Repair queued
Form Focus Group Modera Youth Focus Group	Form and Instruction	New	Repair queued
Form Youth Assent Form Screener (Youth)	Form and Instruction	New	Repair queued
Form Focus Group Screen Screener (Parent)	Form and Instruction	New	Repair queued
OMB SS-B 09.23.13.doc	Supporting Statement B	Uploaded 2013-09-23	Repair queued
Attachment E - Invitation Letter for Health Care Provider Interviews.docx	Supplementary Document	Uploaded 2013-09-23	Repair queued
Attachment D - Project Design.docx	Supplementary Document	Uploaded 2013-09-23	Repair queued
Attachment F - Parent Consent Form.doc	Supplementary Document	Uploaded 2013-09-23	Repair queued
Attachment H - Trevor Comments - SAMHSA Tobacco - 09-13 -13.pdf	Supplementary Document	Uploaded 2013-09-23	Repair queued
OMB SS-A 09.23.13.doc	Supporting Statement A	Uploaded 2013-09-23	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208789	Provider Interview	Form and Instruction	New
208788	Youth Focus Group	Form and Instruction	New
208787	Screener (Youth)	Form and Instruction	New
208786	Screener (Parent)	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 201309-0930-002
Status: Historical Inactive	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 20583
Title: SAMHSA Tobacco Prevention, Cessation, and Behavioral Health Message Testing
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OIRA Conclusion Action: Withdrawn	Conclusion Date: 01/08/2014
	Date Received in OIRA: 09/24/2013
Terms of Clearance: SAMHSA requests to withdraw this collection for time and funding reasons.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date		12 Months From Approved
Responses	0	0	0
Time Burden (Hours)	0	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The primary goal of the project is to inform messaging efforts that improve tobacco use prevention and cessation efforts in populations with mental health and substance use concerns, particularly youth and vulnerable populations. Focus groups with youth and interviews with healthcare professionals are an integral part of the process to test messages and, ultimately, develop effective campaign materials and efficient implementation plans.

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Authorizing Statute(s): US Code: 42 USC 505 Name of Law: Data Collection
  

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 45254	07/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 58325	09/23/2013
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
Screener (Parent)	Focus Group Screener	Focus Group Screener
Screener (Youth)	Youth Assent Form, Focus Group Moderator's Guide	Youth Assent Form ,   Focus Group Moderator's Guide
Youth Focus Group	Focus Group Moderator's Guide	Focus Group Moderator's Guide
Provider Interview	Health Care Professional Interview Guide	Health Care Professional Interview Guide

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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: $309,350

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: 09/24/2013

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