Behavioral Health Information Technologies Survey

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form BHITS BHIT Survey	Form and Instruction	New	Available
Attachment 6_ScrennShots._5_27_15pdf	Supplementary Document	Uploaded 2015-07-16	Available
Attachment 5_GranteeLetter_2_27_15.doc	Supplementary Document	Uploaded 2015-07-16	Available
Attachment 4_Pilot_Protocol_Schedule_Documents-2_27_15.docx	Supplementary Document	Uploaded 2015-07-16	Available
Attachment 3_Survey Question Crosswalk to Research Question and Domain_052215.docx	Supplementary Document	Uploaded 2015-07-16	Available
Attachment 2_Data Dictionary-Key-Terms-Definitions_2_27_15.docx	Supplementary Document	Uploaded 2015-07-16	Available
OMB SS-A__5_28_15.docx	Supporting Statement A	Uploaded 2015-05-28	Available
Attachment_8_ResponsetoPublicComment.docx	Supplementary Document	Uploaded 2015-05-28	Available
Attachment_7_PublicComment.docx	Supplementary Document	Uploaded 2015-05-28	Available
OMB SS-B_7_23_15..docx	Supporting Statement B	Uploaded 2015-07-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
216733	BHIT Survey	Form and Instruction	New

ICR Details

OMB Control No: 0930-0352	ICR Reference No: 201505-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Behavioral Health Information Technologies Survey
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: 07/24/2015
	Date Received in OIRA: 06/01/2015
Terms of Clearance: In accordance with 5 CFR 1320, this information collection is approved for 3 years.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2018	36 Months From Approved
Responses	374	0	0
Time Burden (Hours)	150	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: This survey will collect the necessary standardized, baseline data on the state of adoption of HIT by behavioral health providers within SAMHSA grant programs. The survey was developed with attention to the varying types of levels of HIT tools and applications that behavioral health providers might be adopting into their practices.

---

Authorizing Statute(s): US Code: 42 USC 290 Name of Law: Report on Individuals with Co-Occurring Mental Illness and Substance Abuse Disorders
  

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:
	80 FR 13867	03/17/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 28281	05/18/2015
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
BHIT Survey	BHITS	BHITS

---

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	374	0	0	374	0	0
Annual Time Burden (Hours)	150	0	0	150	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.

---

Annual Cost to Federal Government: $662,747

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

---

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: 06/01/2015

---