Minority Substance Abuse/HIV Prevention Initiative

Forms and Documents

Document	Type	Status	Availability
Form Group Dosage Form Group Dosage Form	Form and Instruction	New	Repair queued
Form Individual Dosage Individual Dosage Form	Form and Instruction	New	Available
Form Youth Questionnair Youth	Form and Instruction	Modified	Available
Form Adult Questionnair Adult	Form and Instruction	Modified	Repair queued
MAI_SS-A_12.22.15.docx	Supporting Statement A	Uploaded 2015-12-22	Available
5.MAIOverarchingGuide_OMB.150810.docx	Supplementary Document	Uploaded 2015-12-21	Available
MAI-SS-B_12.21.15.docx	Supporting Statement B	Uploaded 2015-12-21	Available

IC Document Collections

IC ID	Collection	Type	Status	Form
219369	Group Dosage Form	Form and Instruction	New
219368	Individual Dosage Form	Form and Instruction	New
203550	Youth	Form and Instruction	Modified
187120	Adult	Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0298	ICR Reference No: 201512-0930-003
Status: Historical Active	Previous ICR Reference No: 201208-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Minority Substance Abuse/HIV Prevention Initiative
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: 03/15/2016
	Date Received in OIRA: 12/22/2015
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	03/31/2016
Responses	235,980	0	20,512
Time Burden (Hours)	35,139	0	15,049
Cost Burden (Dollars)	0	0	0

---

Abstract: The Youth and Adult Minority Substance Abuse Questionnaires will be used to survey populations at risk for Substance Abuse, HIV/AIDS, and hepatitis. The participants are those in the Program who receive direct services for over 30 days at three time points: (1) baseline (program entry), (2) program exit, and (3) three to six months post-exit.

---

Authorizing Statute(s): US Code: 42 USC 516 Name of Law: Priority Substance Abuse Prevention Needs of Reginional 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 58742	09/30/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 12345	12/22/2015
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Adult	Adult Questionnaire	Adult Questionnaire
Youth	Youth Questionnaire	Youth Questionnaire
Group Dosage Form	Group Dosage Form	Group Dosage Form
Individual Dosage Form	Individual Dosage Form	Individual Dosage 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	235,980	20,512	0	215,468	0	0
Annual Time Burden (Hours)	35,139	15,049	0	20,090	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: Changing Regulations

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Currently there were 16,770 hours in the OMB inventory. SAMHSA is requesting 35,139 to continue this cross-site evaluation. The additional 18,369 hours are due to program changes, including an increase in the number of grantees funded by the MSI CBO and CBI programs and related increase in the expected numbers of participants to be served. Additionally, the estimates of the number of participants by service duration and of response rates to the surveys are based on data submitted by more recent cohorts and are more representative of the probable activities of the current cohorts of grantees. Finally, two brief dosage forms have been added to the data collection protocol.

---

Annual Cost to Federal Government: $606,800

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: 12/22/2015

---