SAMHSA Checklist for SF-5161

Forms and Documents

Document Name	Status
Form Checklist SF-5161 SAMHSA Checklist for SF-5161 Form and Instruction	Modified
0930-0367-SF-5161-SS-A 5.8.17.docx Supporting Statement A	2017-05-08

IC Document Collections

IC ID	Document Title	Status
180307	SAMHSA Checklist for SF-5161 Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0367	ICR Reference No: 201705-0930-001
Status: Historical Active	Previous ICR Reference No: 201701-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 20358
Title: SAMHSA Checklist for SF-5161
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: 06/27/2017
	Date Received in OIRA: 05/10/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved	06/30/2017
Responses	2,669	0	7,457
Time Burden (Hours)	801	0	19,930
Cost Burden (Dollars)	0	0	0

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Abstract: SAMHSA's Checklist assists applicants and recipients to ensure that they have included all required information necessary to process new and continuation applications as well as the name, title, and phone number of the current business official and project director responsible for carrying out the project. Checklist information concerning the type of application is also needed since new, competing continuation; noncompeting continuation and supplemental applications are separated and reviewed differently. The checklist data helps to reduce the time required to process and review grant applications, expediting the issuance of grant awards as well as ensure collection of essential recipient contact information.

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Authorizing Statute(s): US Code: 42 USC 501 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:
	82 FR 12984	03/08/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 21402	05/08/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
SAMHSA Checklist for SF-5161	Checklist SF-5161	Checklist SF-5161

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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	2,669	7,457	0	-4,788	0	0
Annual Time Burden (Hours)	801	19,930	0	-19,129	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Currently there are 19,930 total burden hours in the OMB inventory. SAMHSA is requesting 801 hours. This program change of -19,129 hours is due to the following: CDC and HRSA no longer use the SF-5161 checklist form; and SAMHSA is only using the Checklist, not the Narrative.

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Annual Cost to Federal Government: $30,507

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: 05/10/2017

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