Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Individual_Family_ Individual/Family Crisis Counseling Servies Encounter Log	Form and Instruction	Modified	Available
Form Service_Provider_F Service Provider Feedback Form	Form and Instruction	Modified	Available
Form Participant_Feedba Particpant Feedback Form	Form and Instruction	Modified	Available
Form Adult_Assessment_a Asessment and Referral Tool	Form and Instruction	Modified	Available
Form Weekly_Tally_Sheet Weekly Tally Sheet	Form and Instruction	Modified	Available
Form Group_Encounter_Lo Group Encounter Log	Form and Instruction	Modified	Available
OMB CCP Data SS-A 7.29.15.docx	Supporting Statement A	Uploaded 2015-07-29	Available
OMB CCP Data SS-B 4.18.15.docx	Supporting Statement B	Uploaded 2015-07-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form and Instruction	Modified
201612	Service Provider Feedback Form	Form and Instruction	Modified
201611	Particpant Feedback Form	Form and Instruction	Modified
201610	Asessment and Referral Tool	Form and Instruction	Modified
201609	Weekly Tally Sheet	Form and Instruction	Modified
201608	Group Encounter Log	Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0270	ICR Reference No: 201507-0930-001
Status: Historical Active	Previous ICR Reference No: 201203-0930-002
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)
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: 09/30/2015
	Date Received in OIRA: 07/30/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2018	36 Months From Approved	09/30/2015
Responses	53,000	0	53,000
Time Burden (Hours)	7,638	0	7,622
Cost Burden (Dollars)	0	0	0

---

Abstract: Data collection about services delivered and users of the services will be collected from the CCPs through standardized information tools which will then be reported to SAMHSA for appropriate processing and analysis. CCPs will be required to use the tools for data collection throughout the life of the program.

---

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

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 28283	05/18/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 44981	07/28/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Particpant Feedback Form	Participant_Feedback_Form	Participant_Feedback_Form
Service Provider Feedback Form	Service_Provider_Feedback_Form	Service_Provider_Feedback_Form
Individual/Family Crisis Counseling Servies Encounter Log	Individual_Family_Encounter_Form	Individual_Family_Encounter_Form
Group Encounter Log	Group_Encounter_Log	Group_Encounter_Log
Weekly Tally Sheet	Weekly_Tally_Sheet	Weekly_Tally_Sheet
Asessment and Referral Tool	Child_Youth_Assessment_and_Referral, Adult_Assessment_and_Referral_Tool	Adult_Assessment_and_Referral_Tool ,   Child_Youth_Assessment_and_Referral

---

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	53,000	53,000	0	0	0	0
Annual Time Burden (Hours)	7,638	7,622	0	0	16	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: SAMHSA/CMHS is requesting a minimum increase in burden. The adjustment in burden will increase from previously approved 7,622 total burden hours to 7,638; 16 hours.

---

Annual Cost to Federal Government: $59,619,000

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]? 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: 07/30/2015

---