Co-location and Integration of HIV Prevention and Medical Care into Behavioral Health Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Program Specific I HIV Indicators	Form and Instruction	New	Available
Form TRAC TRAC	Form and Instruction	New	Available
Form HIV Testing Form HIV Testing Form	Form and Instruction	New	Available
Attachment 6 KARNOFSKY PERFORMANCE STATUS SCALE.doc	Supplementary Document	Uploaded 2014-09-08	Available
Attachment 5 CGI Scale.pdf	Supplementary Document	Uploaded 2014-09-08	Available
Attachment 4 Composition of Proposed CoC TRACTool.docx	Supplementary Document	Uploaded 2014-09-08	Repair queued
HIV Supporting Statement - A.docx	Supporting Statement A	Uploaded 2014-06-26	Available
HIV Supporting Statement - B.docx	Supporting Statement B	Uploaded 2014-06-25	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
212088	HIV Indicators	Form and Instruction	New
212087	TRAC	Form and Instruction	New
212075	HIV Testing Form	Form and Instruction	New

ICR Details

OMB Control No: 0930-0343	ICR Reference No: 201406-0930-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Co-location and Integration of HIV Prevention and Medical Care into Behavioral Health Program
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: 09/10/2014
	Date Received in OIRA: 07/03/2014
Terms of Clearance: As shown by the changes to this collection, SAMHSA shall upload all relevant forms. In addition, SAMHSA shall make clear to respondents the expectations at follow-up. Finally, prior to further approval, SAMHSA shall report on progress to the electronic data platform.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2017	36 Months From Approved
Responses	7,516	0	0
Time Burden (Hours)	1,143	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The program is designed to support integrated behavioral health and physical health services for racial/ethnic populations at high risk for behavioral health disorders and at high risk for contracting HIV. This information collection is needed to provide SAM with objective information to document the reach and impact of the Co-location and Integration of HIV Prevention and Medical Care into Behavioral Health program. The information will be used to monitor quality assurance and quality performance outcomes for organizations funded by this grant program. The information will also be used to assess the impact of services on behavioral health and physical health services for individuals served by this program.

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Authorizing Statute(s): US Code: 41 USC 290aa-4 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 23000	04/25/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 36080	06/25/2014
Did the Agency receive public comments on this ICR? No

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

table that charts list of burden

IC Title	Form No.	Form Name
HIV Testing Form	HIV Testing Form	HIV Testing Form
TRAC	TRAC	TRAC
HIV Indicators	Program Specific Indicators	Program Specific Indicators

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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	7,516	0	0	7,516	0	0
Annual Time Burden (Hours)	1,143	0	0	1,143	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: $1,004,000

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 07/03/2014

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