Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form RNS StateTribal RNS StateTribal	Form and Instruction	Modified	Available
Form BHPS StateTribal BHPS StateTribal	Form and Instruction	Modified	Available
Form D8. TUP-S-A Consen D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx	Form and Instruction	Removed	Available
Form D7.Training Utiliz D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx	Form and Instruction	Removed	Available
Form Campus--Provider ( Campus--Provider (Trainees) Instruments	Form and Instruction	Removed	Available
Form SMSS Campus SMSS Campus	Form and Instruction	Modified	Available
Form TUP-S Campus TUP-S Campus	Form and Instruction	Modified	Available
Form SBHF Data Abstract SBHF Data Abstraction Campus	Form and Instruction	Modified	Available
Form TASP Campus TASP Campus	Form and Instruction	Modified	Available
Form PSI Campus PSI Campus	Form and Instruction	Modified	Available
Form Provider Trainee I Provider Trainee Instruments	Form and Instruction	Modified	Available
Form EIRF-Screening For EIRF-Screening Form StateTribal	Form and Instruction	Modified	Available
Form EIRF-Individual Fo EIRF-Individual Form StateTribal	Form and Instruction	Modified	Repair queued
Form TASP StateTribal TASP StateTribal	Form and Instruction	Modified	Available
Form PSI StateTribal PSI StateTribal	Form and Instruction	Modified	Available
Att Q. Privacy Impact Assessment Form (Nov 2013).docx	Supplementary Document	Uploaded 2015-12-23	Available
Att P. Data Use and Access Agreement for review_Formatted.docx	Supplementary Document	Uploaded 2015-12-23	Available
Att O. Suicide Safer Environment Study Logic Model.docx	Supplementary Document	Uploaded 2015-12-23	Available
Att N. Continuity of Care Study Logic Model.docx	Supplementary Document	Uploaded 2015-12-23	Available
Att M. Trainining Study Logic Model.docx	Supplementary Document	Uploaded 2015-12-23	Available
Att B. NOE Instrument Table.docx	Supplementary Document	Uploaded 2015-12-23	Available
Att A. GLS Memorial Act_Final.docx	Supplementary Document	Uploaded 2015-12-23	Available
SS Part B 09.07.15.docx	Supporting Statement B	Uploaded 2015-12-23	Available
SS Part A 12.15.15.docx	Supporting Statement A	Uploaded 2015-12-23	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208304	Behavioral Health Providers/Stakeholders - State/Tribal	Form and Instruction	Modified	RNS StateTribal
208304	Behavioral Health Providers/Stakeholders - State/Tribal	Form and Instruction	Modified	BHPS StateTribal
208303	Adolescents - State/Tribal - Trainees	Form and Instruction	Removed	D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx
208303	Adolescents - State/Tribal - Trainees	Form and Instruction	Removed	D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx
178437	Providers - Campus - Trainees	Form and Instruction	Removed	Campus--Provider (Trainees) Instruments
178435	Student - Campus	Form and Instruction	Modified	SMSS Campus
178435	Student - Campus	Form and Instruction	Modified	TUP-S Campus
178434	Project Evaluators - Campus	Form and Instruction	Modified	SBHF Data Abstraction Campus
178434	Project Evaluators - Campus	Form and Instruction	Modified	TASP Campus
178434	Project Evaluators - Campus	Form and Instruction	Modified	PSI Campus
178433	Providers Trainees - State/Tribal	Form and Instruction	Modified	Provider Trainee Instruments
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	EIRF-Screening Form StateTribal
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	EIRF-Individual Form StateTribal
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	TASP StateTribal
178432	Project Evaluators - State/Tribal	Form and Instruction	Modified	PSI StateTribal

ICR Details

OMB Control No: 0930-0286	ICR Reference No: 201512-0930-006
Status: Historical Active	Previous ICR Reference No: 201308-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 20339
Title: Cross-Site Evaluation of the Garrett Lee Smith Memorial Suicide Prevention and Early Intervention Program
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
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/28/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2019	36 Months From Approved	01/31/2017
Responses	12,902	0	20,347
Time Burden (Hours)	4,129	0	8,014
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected through the four stages of the cross-site evaluation of the GLS Suicide Prevention and Early Intervention Programs will describe for State/Tribal grantees (1) the context in which suicide prevention activities are being implemented, (2) the products and services funded through the program, (3) the training experiences of individuals who receive training as part of the suicide prevention programs, (4) the utilization and penetration of the skills, knowledge and techniques learned through suicide prevention training programs, and (5) the referral networks in place to support youth identified at risk for suicide.

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Authorizing Statute(s): US Code: 42 USC 520E-2 Name of Law: Mental and Bhavioral Health Services on Campus
  

Citations for New Statutory Requirements: None

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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:
	80 FR 60694	10/07/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 80376	12/24/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Adolescents - State/Tribal - Trainees	D7.Training Utilization and Preservation Survey , D8. TUP-S-A Consent-to-Contact	D7.Training Utilization and Preservation Survey (TUP-S-A)- Adolescent Version.docx ,   D8. TUP-S-A Consent-to-Contact and Youth Assent Forms.docx
Behavioral Health Providers/Stakeholders - State/Tribal	RNS StateTribal, BHPS StateTribal	BHPS StateTribal ,   RNS StateTribal
Project Evaluators - Campus	SBHF Data Abstraction Campus, PSI Campus , TASP Campus	PSI Campus ,   TASP Campus ,   SBHF Data Abstraction Campus
Project Evaluators - State/Tribal	PSI StateTribal , TASP StateTribal , EIRF-Screening Form StateTribal, EIRF-Individual Form StateTribal	PSI StateTribal ,   TASP StateTribal ,   EIRF-Individual Form StateTribal ,   EIRF-Screening Form StateTribal
Providers - Campus - Trainees	Campus--Provider (Trainees) Instruments	Campus--Provider (Trainees) Instruments
Providers Trainees - State/Tribal	Provider Trainee Instruments	Provider Trainee Instruments
Student - Campus	SMSS Campus, TUP-S Campus	TUP-S Campus ,   SMSS Campus

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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	12,902	20,347	0	-7,445	0	0
Annual Time Burden (Hours)	4,129	8,014	0	-3,885	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 8,014 annual burden hours in the OMB inventory. SAMHSA is requesting 4,129 annual burden hours for this submission, representing a program change of a decrease of 3,885 annual burden hours. More Details are described in supporting statement - A - section 15.

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Annual Cost to Federal Government: $4,339,803

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

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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: 12/28/2015

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