Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)

Forms and Documents

Document Name	Status
Form Stakeholder Survey Stakeholder Survey Form and Instruction	Modified
Form Client 6-Month Int 6 Month Followup Form and Instruction	Modified
Form Client Baseline In Baseline Form and Instruction	Modified
0320_OMB Supporting Statement-B_2.21.14.doc Supporting Statement B	2014-03-14
Att 07_Stakeholder Survey Consent Form.doc Supplementary Document	2014-03-14
Att 06_Client Interview Consent Form.doc Supplementary Document	2014-03-14
Att 05_Client Interview Script.doc Supplementary Document	2014-03-14
Att 04_SAMHSA Response to OMB_3.3.2011.docx Supplementary Document	2014-03-14
0320_OMB Supporting Statement-A_2.21.14.doc Supporting Statement A	2014-03-14

IC Document Collections

IC ID	Document Title	Status
195856	Stakeholder Survey Form and Instruction	Modified
195855	6 Month Followup Form and Instruction	Modified
195854	Baseline Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0320	ICR Reference No: 201403-0930-005
Status: Historical Active	Previous ICR Reference No: 201012-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 21577
Title: Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/29/2014
	Date Received in OIRA: 03/17/2014
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved	05/31/2014
Responses	11,241	0	11,241
Time Burden (Hours)	4,006	0	4,006
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected through all three surveys (Baseline and 6-month Followup, and Stakeholder Survey) will provide the data necessary to conduct a complete structure, process, outcome, and cost evaluation. The data collected through the Stakeholder Survey will provide descriptive information about stakeholders involved with the CSAT GBHI grant program and their relationship with the grantee program.

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Authorizing Statute(s): US Code: 42 USC 290 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:
	79 FR 2188	01/13/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 14262	03/13/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Baseline	Client Baseline Interview	Client Baseline Interview
6 Month Followup	Client 6-Month Interview	Client 6-Month Interview
Stakeholder Survey	Stakeholder Survey	Stakeholder Survey

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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	11,241	11,241	0	0	0	0
Annual Time Burden (Hours)	4,006	4,006	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $65,305

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: 03/17/2014

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