Community Support Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form ENFG Employment Sp ENFG Employment Specialist Version	Form and Instruction	New	Available
Form ENFG Employer Vers ENFG Employer Version	Form and Instruction	New	Available
Form SSA KII Service Pr SSA KII Service Provider Version	Form and Instruction	New	Available
Form SSA KII Administra SSA KII Administrator Version	Form and Instruction	New	Available
Form BPI SE Version BPI SE Version	Form and Instruction	New	Available
Form Concept Mapping So Concept Mapping Sorting and Rating Activity	Form and Instruction	New	Available
Form Concept Mapping Br Concept Mapping Brainstorming Activity	Form and Instruction	New	Available
Form Comparison Study T Comparison Study Tool (6 Month)	Form and Instruction	New	Available
Form Comparison Study T Comparison Study Tool (18 Month)	Form and Instruction	New	Available
Form Comparison Study T Comparison Study Tool (Baseline).	Form and Instruction	New	Available
Form SLA KII Consumer V SLA KII Consumer Version	Form and Instruction	New	Available
Form SLA KII Service Pr SLA KII Service Provider Version	Form and Instruction	New	Available
Form SLA KII Court Pers SLA KII Court Personnel Version	Form and Instruction	New	Available
Form 18-Month Client-Le 18-Month Client-Level Abstraction Tool	Form and Instruction	New	Available
Form BPI BHTCC Version BPI BHTCC Version	Form and Instruction	New	Available
CSE SS Part A for SAMHSA_031116.docx	Supporting Statement A	Uploaded 2016-03-11	Available
CSE SS Part B FINAL_090816.docx	Supporting Statement B	Uploaded 2016-09-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
220576	Employment Specialists	Form and Instruction	New	ENFG Employment Specialist Version
220575	Hiring Managers	Form and Instruction	New	ENFG Employer Version
220574	SE Service Providers	Form and Instruction	New	SSA KII Service Provider Version
220572	Administrators	Form and Instruction	New	SSA KII Administrator Version
220571	Project Directors	Form and Instruction	New	BPI SE Version
220569	BHTCC Stakeholders	Form and Instruction	New	Concept Mapping Sorting and Rating Activity
220569	BHTCC Stakeholders	Form and Instruction	New	Concept Mapping Brainstorming Activity
220567	Court Clerks	Form and Instruction	New	Comparison Study Tool (6 Month)
220567	Court Clerks	Form and Instruction	New	Comparison Study Tool (18 Month)
220567	Court Clerks	Form and Instruction	New	Comparison Study Tool (Baseline).
220566	Consumers	Form and Instruction	New	SLA KII Consumer Version
220565	BHTCC Service Providers	Form and Instruction	New	SLA KII Service Provider Version
220564	Court Personnel	Form and Instruction	New	SLA KII Court Personnel Version
220563	Project Evaluators	Form and Instruction	New	18-Month Client-Level Abstraction Tool
220563	Project Evaluators	Form and Instruction	New	BPI BHTCC Version

ICR Details

OMB Control No: 0930-0363	ICR Reference No: 201603-0930-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Community Support 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 with change	Conclusion Date: 09/21/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/11/2016
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved
Responses	687	0	0
Time Burden (Hours)	561	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the CSE is to (1) describe and assess BHTCC and SE grantee activities and procedures, including the intermediate or direct effects of the programs on participants; (2) document the application and sanctioned adaptations of BHTCC programs in the justice system and of the SE Program; and (3) design and implement plans to disseminate knowledge about how to replicate effective projects in other States, territories, tribal nations, and communities.

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Authorizing Statute(s): US Code: 42 USC 290aa Name of Law: Data Collection
  

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 79349	12/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 10641	03/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
Administrators	SSA KII Administrator Version	SSA KII Administrator Version
BHTCC Service Providers	SLA KII Service Provider Version	SLA KII Service Provider Version
BHTCC Stakeholders	Concept Mapping Brainstorming Activity, Concept Mapping Sorting and Rating Activity	Concept Mapping Brainstorming Activity ,   Concept Mapping Sorting and Rating Activity
Consumers	SLA KII Consumer Version	SLA KII Consumer Version
Court Clerks	Comparison Study Tool (6 Month), Comparison Study Tool (Baseline)., Comparison Study Tool (18 Month)	Comparison Study Tool (Baseline). ,   Comparison Study Tool (18 Month) ,   Comparison Study Tool (6 Month)
Court Personnel	SLA KII Court Personnel Version	SLA KII Court Personnel Version
Employment Specialists	ENFG Employment Specialist Version	ENFG Employment Specialist Version
Hiring Managers	ENFG Employer Version	ENFG Employer Version
Project Directors	BPI SE Version	BPI SE Version
Project Evaluators	BPI BHTCC Version, 18-Month Client-Level Abstraction Tool	BPI BHTCC Version ,   18-Month Client-Level Abstraction Tool
SE Service Providers	SSA KII Service Provider Version	SSA KII Service Provider Version

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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	687	0	0	687	0	0
Annual Time Burden (Hours)	561	0	0	561	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: $1,674,392

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: 03/11/2016

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