Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form TA Customer Satisf TA Customer Satisfaction Feedback Form	Form and Instruction	New	Available
Form Public Website and Public Website and TA Gateway Feedback Forms	Form and Instruction	New	Available
Form Offsite In Person Offsite In Person Training Feedback Form	Form and Instruction	New	Available
Form Onsite In Person T Onsite In Person Training Feedback Form	Form and Instruction	New	Available
Form NRC Online Module NRC Online Module Feedback Form	Form and Instruction	New	Available
Form NRC Online Feedbac NRC Online Feedback Form	Form and Instruction	New	Available
Form MAT APP MAT APP	Form and Instruction	New	Available
Form Survey Survey	Form and Instruction	New	Available
Form Survey Survey	Form and Instruction	New	Available
Form KAP Survey KAP Survey	Form and Instruction	New	Available
Form Survey Survey	Form and Instruction	New	Available
Form Modified TA Networ Modified TA Network Satisfaction Survey	Form and Instruction	New	Available
Form SBIRT Organization SBIRT Organizational Readiness and Satisfaction Survey	Form and Instruction	New	Available
Form Case Study Protoco Case Study Protocol/Focus Groups	Form and Instruction	New	Available
Form TTA Tool TTA Tool	Form and Instruction	New	Available
Form On-Line Tutorials On-Line Tutorials	Form and Instruction	New	Available
Form Contact Center Sur Contact Center Survey	Form and Instruction	New	Available
Form Suicide Prevention Suicide Prevention Survey	Form and Instruction	New	Available
Form Bulling Prevention Bulling Prevention Survey	Form and Instruction	New	Available
Customer Feedback Surveys OMB Request 6-27-14.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2014-07-02	Available
0197-12.16.13-SS-B.doc	Supporting Statement B	Uploaded 2014-01-02	Available
0197-12.16.13-SS-A.doc	Supporting Statement A	Uploaded 2014-01-02	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	TA Customer Satisfaction Feedback Form
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	Public Website and TA Gateway Feedback Forms
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	Offsite In Person Training Feedback Form
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	Onsite In Person Training Feedback Form
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	NRC Online Module Feedback Form
224057	National Resource for MH Promotion and Youth Violence Prevention	Form and Instruction	New	NRC Online Feedback Form
220719	Medication-Assisted Treatment (MAT) Application	Form and Instruction	New	MAT APP
219144	GDTA Learning Community	Form and Instruction	New	Survey
219133	GDTA - TA	Form and Instruction	New	Survey
218767	Knowledge Application Program Product	Form and Instruction	New	KAP Survey
216913	Public Engagement Platform	Form and Instruction	New	Survey
214995	Annual Generalized TA Survey	Form and Instruction	New	Modified TA Network Satisfaction Survey
214917	SBIRT Organizational Readiness and Satisfaction Survey	Form and Instruction	New	SBIRT Organizational Readiness and Satisfaction Survey
213731	Case Study Protocol/Focus Groups	Form and Instruction	New	Case Study Protocol/Focus Groups
213726	Impact of Training and Technical Assistance Tool	Form and Instruction	New	TTA Tool
213279	On-Line Tutorials	Form and Instruction	New	On-Line Tutorials
212169	Public Engagement Platform Surveys	Form and Instruction	New	Contact Center Survey
212169	Public Engagement Platform Surveys	Form and Instruction	New	Suicide Prevention Survey
212169	Public Engagement Platform Surveys	Form and Instruction	New	Bulling Prevention Survey

ICR Details

OMB Control No: 0930-0197	ICR Reference No: 201406-0930-006
Status: Historical Active	Previous ICR Reference No: 201401-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 21282
Title: Voluntary Customer Satisfaction Surveys to Implement Executive Order 12862 in the Substance Abuse and Mental Health Services Administration (SAMHSA)
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/29/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/02/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2017	01/31/2017	01/31/2017
Responses	90,000	0	90,000
Time Burden (Hours)	23,063	0	23,063
Cost Burden (Dollars)	0	0	0

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Abstract: SAMHSA provides significant services directly to the public, including treatment providers and State substance abuse agencies, through a range of mechanisms, including publications, technical assistance and web sites. Many of these services are focused on information dissemination activities. The purpose of this submission is to obtain generic approval for satisfaction surveys of our customers.

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Authorizing Statute(s): US Code: 42 USC 501 Name of Law: SAMHSA
  

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 64520	10/29/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 78986	12/27/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 12

table that charts list of burden

IC Title	Form No.	Form Name
Annual Generalized TA Survey	Modified TA Network Satisfaction Survey	Modified TA Network Satisfaction Survey
Case Study Protocol/Focus Groups	Case Study Protocol/Focus Groups	Case Study Protocol/Focus Groups
GDTA - TA	Survey	Survey
GDTA Learning Community	Survey	Survey
Impact of Training and Technical Assistance Tool	TTA Tool	TTA Tool
Knowledge Application Program Product	KAP Survey	KAP Survey
Medication-Assisted Treatment (MAT) Application	MAT APP	MAT APP
National Resource for MH Promotion and Youth Violence Prevention	NRC Online Feedback Form, NRC Online Module Feedback Form, Onsite In Person Training Feedback Form, Offsite In Person Training Feedback Form, Public Website and TA Gateway Feedback Forms, TA Customer Satisfaction Feedback Form	NRC Online Feedback Form ,   NRC Online Module Feedback Form ,   Onsite In Person Training Feedback Form ,   Offsite In Person Training Feedback Form ,   Public Website and TA Gateway Feedback Forms ,   TA Customer Satisfaction Feedback Form
On-Line Tutorials	On-Line Tutorials	On-Line Tutorials
Public Engagement Platform	Survey	Survey
Public Engagement Platform Surveys	Contact Center Survey, Bulling Prevention Survey, Suicide Prevention Survey	Bulling Prevention Survey ,   Suicide Prevention Survey ,   Contact Center Survey
SBIRT Organizational Readiness and Satisfaction Survey	SBIRT Organizational Readiness and Satisfaction Su	SBIRT Organizational Readiness and Satisfaction Survey

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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	90,000	90,000	0	0	0	0
Annual Time Burden (Hours)	23,063	23,063	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: There is no burden change.

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Annual Cost to Federal Government: $2,367,015

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: 07/02/2014

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