Hospital Data Abstraction Form, Evaluation of Emergency Department Crisis Center Follow-up

Forms and Documents

Document	Type	Status	Availability
Form Crisis Center Data Crisis Center Data Abstraction Form	Form and Instruction	Removed	Repair queued
Form Hospital Data Abst Hospital Data Abstraction Form	Form and Instruction	Modified	Repair queued
ED Supporting Statement_B 9.17.15.docx	Supporting Statement B	Uploaded 2015-09-29	Available
ED Supporting Statement_A 9.17.15.docx	Supporting Statement A	Uploaded 2015-09-29	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
206304	Crisis Center Data Abstraction Form	Form and Instruction	Removed
206303	Hospital Data Abstraction Form	Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0337	ICR Reference No: 201509-0930-002
Status: Historical Active	Previous ICR Reference No: 201303-0930-003
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 19137
Title: Hospital Data Abstraction Form, Evaluation of Emergency Department Crisis Center Follow-up
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: 12/09/2015
	Date Received in OIRA: 09/30/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	12/31/2018	36 Months From Approved	09/30/2016
Responses	10,011	0	1,000
Time Burden (Hours)	401	0	40
Cost Burden (Dollars)	0	0	0

---

Abstract: The overall aim of the project will be to determine the extent to which this collaboration between crisis centers and hospital emergency departments impacts readmission rates for suicidal behavior. This information will be used to advance the field of crisis center support to persons in crisis and inform future directions of the Lifeline.

---

Authorizing Statute(s): US Code: 42 USC 520A Name of Law: Priority Mental Health Needs of the Regional and National Significance
  

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 40073	07/13/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 57627	09/24/2015
Did the Agency receive public comments on this ICR? No

---

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

IC Title	Form No.	Form Name
Hospital Data Abstraction Form	Hospital Data Abstraction Form	Hospital Data Abstraction Form
Crisis Center Data Abstraction Form	Crisis Center Data Abstraction Form	Crisis Center Data Abstraction Form

---

ICR Summary 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	10,011	1,000	0	9,011	0	0
Annual Time Burden (Hours)	401	40	0	361	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 40 burden hours in the OMB inventory. SAMHSA is requesting 401 total burden hours, and increase of 361. This increase is due to a program change of the expansion of data collection for the Hospital Data Abstraction Form from two to thirty hospital staff respondents (one respondent per hospital). The resulting estimated annual burden is 401 hours, an increase from the original estimated annual burden of 27 hours for the form. Data collection associated with the Crisis Center Data Abstraction Form is being discontinued, resulting in the removal of an estimated annual burden of 13 hours.

---

Annual Cost to Federal Government: $253,112

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: 09/30/2015

---