Violence Intervention to Enhance Lives (VITEL) Supplemental Grant Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Administrative_Dir Administrative_Direct Staff_Partner_ Data Sheet	Form and Instruction	New	Available
Form Progress Report Progress Report	Form and Instruction	New	Available
Form Partner-Collab SS Partner-Collab SS Interview Guide	Form and Instruction	New	Available
Form Direct Staff SS In Direct Staff SS Interview Guide	Form and Instruction	New	Available
Form Exec-Admin Staff S Exec-Admin Staff SS Interview Guide	Form and Instruction	New	Available
Form SIX MONTH FOLLOW-U SIX MONTH FOLLOW-UP Client Level Survey	Form and Instruction	New	Available
Form DISCHARGE Client L DISCHARGE Client Level Survey	Form and Instruction	New	Available
Form BASELINE Client Le BASELINE Client Level Survey	Form and Instruction	New	Available
Form Client Focus Group Client Focus Group	Form and Instruction	New	Available
VITEL - OMB SS-A 1.4.16.docx	Supporting Statement A	Uploaded 2016-01-04	Available
VITEL - OMB SS-B 12.15.15.docx	Supporting Statement B	Uploaded 2016-01-04	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
219468	Executives, PD/PM-Progress Report	Form and Instruction	New	Administrative_Direct Staff_Partner_ Data Sheet
219468	Executives, PD/PM-Progress Report	Form and Instruction	New	Progress Report
219467	Community Collaborators-Semi-Structured Interviews	Form and Instruction	New	Partner-Collab SS Interview Guide
219465	Direct Staff-Semistructured Interviews	Form and Instruction	New	Direct Staff SS Interview Guide
219462	Executives, PD/PM-Semi-Structured Interviews	Form and Instruction	New	Exec-Admin Staff SS Interview Guide
219456	Clients	Form and Instruction	New	SIX MONTH FOLLOW-UP Client Level Survey
219456	Clients	Form and Instruction	New	DISCHARGE Client Level Survey
219456	Clients	Form and Instruction	New	BASELINE Client Level Survey
219456	Clients	Form and Instruction	New	Client Focus Group

ICR Details

OMB Control No: 0930-0355	ICR Reference No: 201601-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Violence Intervention to Enhance Lives (VITEL) Supplemental Grant Evaluation
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 without change	Conclusion Date: 03/15/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/11/2016
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
Responses	1,925	0	0
Time Burden (Hours)	887	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This Evaluation consists of a multi-faceted approach to understanding the impact of intimate partner violence (IPV) screening and referral to trauma-informed care as well as the mechanisms that facilitate positive change in the reduction of IPV, substance use disorder (SUD) and HIV risk behaviors among racial/ethnic women offered through SAMHSA’s Targeted Capacity Expansion: Substance Abuse Treatment for Racial/Ethnic Minority Women at High Risk for HIV/AIDS (TCE-HIV: Minority Women) grant program.

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Authorizing Statute(s): US Code: 42 USC 509 Name of Law: Priority SAT of Regional and National Significance
  

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 25661	10/08/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 80784	12/28/2015
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
Clients	Client Focus Group , BASELINE Client Level Survey , DISCHARGE Client Level Survey , SIX MONTH FOLLOW-UP Client Level Survey	Client Focus Group ,   BASELINE Client Level Survey ,   DISCHARGE Client Level Survey ,   SIX MONTH FOLLOW-UP Client Level Survey
Community Collaborators-Semi-Structured Interviews	Partner-Collab SS Interview Guide	Partner-Collab SS Interview Guide
Direct Staff-Semistructured Interviews	Direct Staff SS Interview Guide	Direct Staff SS Interview Guide
Executives, PD/PM-Progress Report	Administrative_Direct Staff_Partner_ Data Sheet , Progress Report	Progress Report ,   Administrative_Direct Staff_Partner_ Data Sheet
Executives, PD/PM-Semi-Structured Interviews	Exec-Admin Staff SS Interview Guide	Exec-Admin Staff SS Interview Guide

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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	1,925	0	0	1,925	0	0
Annual Time Burden (Hours)	887	0	0	887	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.

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Annual Cost to Federal Government: $19,157

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: 01/11/2016

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