Mulit-Site Evaluation of the Safe Schools/Healthy Students (SS/HS) State Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form School Level Surve School Level Survey	Form and Instruction	New	Available
Form Key Informant Inte Key Informant Interview	Form and Instruction	New	Available
Form District collabora District collaboration indicator data instrument	Form and Instruction	New	Available
Form State collaboratio State collaboration indicator data instrument	Form and Instruction	New	Available
Form District Collabora District Collaborator Survey	Form and Instruction	New	Available
Form State Collaborator State Collaborator Survey	Form and Instruction	New	Available
Form District KII District KII	Form and Instruction	New	Available
Form State KII State KII	Form and Instruction	New	Available
SS-B-SSHS-OMB-01-20-15_FINAL.docx	Supporting Statement B	Uploaded 2015-01-22	Available
SS-A-SSHS-OMB-1-20-15_FINAL.docx	Supporting Statement A	Uploaded 2015-01-22	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
213255	School Level Survey	Form and Instruction	New	School Level Survey
213254	Klls	Form and Instruction	New	Key Informant Interview
213253	District Collaborator Indicator Data Instrument	Form and Instruction	New	District collaboration indicator data instrument
213252	State Collaborator Indicator Data Instrument	Form and Instruction	New	State collaboration indicator data instrument
213251	District Collaborator Survey	Form and Instruction	New	District Collaborator Survey
213250	State Collaborator Survey	Form and Instruction	New	State Collaborator Survey
213249	District Key informant Interviews	Form and Instruction	New	District KII
213246	State Key Informant Interviews	Form and Instruction	New	State KII

ICR Details

OMB Control No: 0930-0347	ICR Reference No: 201409-0930-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Mulit-Site Evaluation of the Safe Schools/Healthy Students (SS/HS) State 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: 01/22/2015
Retrieve Notice of Action (NOA)	Date Received in OIRA: 09/29/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2018	36 Months From Approved
Responses	3,177	0	0
Time Burden (Hours)	1,556	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The evaluation will use two primary study components-the Planning, Collaboration and Partnership (PCP) Study, and the Implementation Study-to investigate the three critical areas of inquiry: 1) Examine the degree to which the SS/HS Framework has been successfully implemented; 2) Assess grant program performance; and 3) Accurately and comprehensively describe the intervention.

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Authorizing Statute(s): US Code: 42 USC 290bb Name of Law: Evaluations Mental Health
  

Citations for New Statutory Requirements: US Code: 42 USC 290bb Name of Law: Evaluations - MH

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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 42026	07/18/2014
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 57118	09/24/2014
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
District Collaborator Indicator Data Instrument	District collaboration indicator data instrument	District collaboration indicator data instrument
District Collaborator Survey	District Collaborator Survey	District Collaborator Survey
District Key informant Interviews	District KII	District KII
Klls	Key Informant Interview	Key Informant Interview
School Level Survey	School Level Survey	School Level Survey
State Collaborator Indicator Data Instrument	State collaboration indicator data instrument	State collaboration indicator data instrument
State Collaborator Survey	State Collaborator Survey	State Collaborator Survey
State Key Informant Interviews	State KII	State KII

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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	3,177	0	0	3,177	0	0
Annual Time Burden (Hours)	1,556	0	0	1,556	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: $570,211

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: 09/29/2014

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