Primary and Behavioral Health Care Integration Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Client Health Asse Client Health Assessment Questionnaire	Form and Instruction	New	Available
Form Electronic Data Co Electronic Data Collection Tool	Form and Instruction	New	Available
Form Electronic Data Co Electronic Data Collection Tool	Form and Instruction	New	Available
Form On-site Staff Inte On-site Staff Interview Protocol	Form and Instruction	New	Available
Form Telephone Intervie Telephone Interview Protocol	Form and Instruction	New	Available
Form Staff Survey Staff Survey	Form and Instruction	New	Available
Form Director Survey Director Survey	Form and Instruction	New	Available
OMB_Part B Final PBHCI 6 24 2016.docx	Supporting Statement B	Uploaded 2016-06-27	Available
OMB_Part A FINAL PBHCI 6 24 2016.docx	Supporting Statement A	Uploaded 2016-06-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
222211	Comparison Group Clinic Director Coordination	Instruction	New
222210	SMI Clients	Form and Instruction	New	Client Health Assessment Questionnaire
222209	Extraction of Grantee Registry/EHR Data	Form and Instruction	New	Electronic Data Collection Tool
222207	Focus Groups	Form and Instruction	New	Electronic Data Collection Tool
222206	Grantee - Site Visits	Form and Instruction	New	On-site Staff Interview Protocol
222205	Grantee Director - Phone	Form and Instruction	New	Telephone Interview Protocol
222204	Grantee Frontline Staff Survey	Form and Instruction	New	Staff Survey
222203	Grantee Director - Web	Form and Instruction	New	Director Survey

ICR Details

OMB Control No: 0930-0365	ICR Reference No: 201605-0930-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Primary and Behavioral Health Care Integration 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: 09/30/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 06/29/2016
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	6,973	0	0
Time Burden (Hours)	10,882	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the PBHCI grants is to improve the overall wellness and physical health of people with serious mental illness (SMI), including people with co-occurring substance use disorders, by helping communities coordinate and integrate primary care services into publicly funded, community-based settings providing mental health and behavioral health care. This data will help SAMHSA assess whether integrated primary care services produce improvements in the physical and mental health of the SMI population receiving services from community-based behavioral health agencies.

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Authorizing Statute(s): US Code: 42 USC 290 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:
	81 FR 12917	03/11/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 29570	05/12/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Comparison Group Clinic Director Coordination
Extraction of Grantee Registry/EHR Data	Electronic Data Collection Tool	Electronic Data Collection Tool
Focus Groups	Electronic Data Collection Tool	Electronic Data Collection Tool
Grantee - Site Visits	On-site Staff Interview Protocol	On-site Staff Interview Protocol
Grantee Director - Phone	Telephone Interview Protocol	Telephone Interview Protocol
Grantee Director - Web	Director Survey	Director Survey
Grantee Frontline Staff Survey	Staff Survey	Staff Survey
SMI Clients	Client Health Assessment Questionnaire	Client Health Assessment Questionnaire

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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	6,973	0	0	6,973	0	0
Annual Time Burden (Hours)	10,882	0	0	10,882	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: $1,352,874

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 06/29/2016

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