Primary and Behavioral Health Care Integration Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Quarterly Report Grantee - Quarterly Reports	Form and Instruction	Modified	Available
Form Physical Health In Client-level interview-Physical Health Indicators	Form and Instruction	Modified	Available
PBHCI-SS-A-8.15.14.doc	Supporting Statement A	Uploaded 2014-08-15	Available
PBHCI-SS-B-8.12.14.doc	Supporting Statement B	Uploaded 2014-08-12	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
198670	Grantee Key Staff- Web Survey	Other-survey	Removed
198669	SMI Clients- Clients Exam and Survey-Follow-up	Other-form	Removed
196137	Grantee - Quarterly Reports	Form and Instruction	Modified
196136	Grantee Data - Individual Service Utilization Data	Other-survey	Removed
196135	Client-level interview-Physical Health Indicators	Form and Instruction	Modified
196134	Control Site leadership - Site visit Interview	Other-survey	Removed
196133	Care coordinators interivew	Other-survey	Removed
196132	MH Provider Interview	Other-survey	Removed
196131	Grantee PH Providers- Site Visit Interview	Other-survey	Removed
196130	Grantee Leadership (Sites Visit Interview)	Other-interview	Removed
196129	SMI Clients -Client Exam and Survey-Baseline	Other-survey	Removed

ICR Details

OMB Control No: 0930-0340	ICR Reference No: 201408-0930-003
Status: Historical Active	Previous ICR Reference No: 201404-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Primary and Behavioral Health Care Integration Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 10/30/2014
	Date Received in OIRA: 08/19/2014
Terms of Clearance: Previous terms of clearance remain in effect.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2017	36 Months From Approved	10/31/2014
Responses	28,280	0	59,865
Time Burden (Hours)	2,800	0	10,057
Cost Burden (Dollars)	0	0	0

---

Abstract: SAMHSA's PBHCI grantees have been developing and implementing an array of integrated services designed to improve the physical and behavioral health status of people with serious mental illnesses, including individuals with co-occurring substance use disorders. These services incorporate a prevention and wellness approach and are provided using different models of cooperation and collaboration between community behavioral health and primary care.

---

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

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 34544	06/17/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 48174	08/15/2014
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Grantee Leadership (Sites Visit Interview)
MH Provider Interview
Care coordinators interivew
Control Site leadership - Site visit Interview
Grantee Data - Individual Service Utilization Data
SMI Clients- Clients Exam and Survey-Follow-up
Client-level interview-Physical Health Indicators	Physical Health Indicators	Physical Health Indicators
Grantee Key Staff- Web Survey
Grantee - Quarterly Reports	Quarterly Report	Quarterly Report
SMI Clients -Client Exam and Survey-Baseline
Grantee PH Providers- Site Visit Interview

---

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	28,280	59,865	0	-31,585	0	0
Annual Time Burden (Hours)	2,800	10,057	0	-7,257	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Currently there are 10,057 burden hours in the OMB inventory. The Program is requesting 2,800 burden hours. This reduction in burden is due to the elimination of several data collection instruments that were collected as part of a previous evaluation, but are no longer included in the current data collection request.

---

Annual Cost to Federal Government: $68,000

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]? Yes

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)? Yes

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

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: 08/19/2014

---