0930-0367-sf-5161-ss-a 5.8.17

SAMHSA Checklist for SF-5161

SUPPORTING STATEMENT

A. JUSTIFICATION

1. Circumstances of Information Collection

The Substance Abuse and Mental Health Services Administration (SAMHSA) is requesting a revision from the Office of Management and Budget (OMB) for the SF-5161-Checklist. SAMHSA is requesting approval to only collect information on the Checklist and not the Narrative. The 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 that is not collected elsewhere. A copy of the document is included in Attachment A.

This data collection has been transferred from HHS to SAMHSA. The current data collection (OMB No. 0930-0367) expires on April 30, 2017.

The checklist is part of the standard application (SF-5161) for State and local governments and for private non-profit and for-profit organizations when applying for health services projects.

Collection of the information included in this request is authorized by Section 505 of the Public Health Service Act (42 USC 290aa-4) – Data Collection.

The legal authorities for the programs requesting use of this form are listed below.

Public Health Service Act, Section:

Integrated Community-Based Primary Care and Drug Abuse Treatment Services;

303: Minority Fellowship Program

303(a)(1): Mental Health Care Provider Education in HIV/AIDS

319: Disaster Assistance (42 U.S.C. 247d)

319B, C, F Public Health Threats and Emergencies Act

501(d)(5): Improved Provision of Mental Health and Substance Abuse Treatment, Prevention and Related Services

507(b)(11), and 511: Demonstration Cooperative Agreements for Development and Implementation of Criminal Justice-Treatment Networks

508: Services Grant Program for Residential Treatment for Pregnant and Postpartum Women

510 (b)(1): Demonstration Grant Program for Residential Treatment for Women and Their Children

510(b)(6): Community-Based Comprehensive HIV/STD/TB Outreach Services for High Risk Substance Abusers Demo. Program.

515(b)(3)and(9): Communications Programs Aimed at Preventing Alcohol and Other Drug

Programs

517: Substance Abuse Prevention Demonstration Grants for High Risk Youth

520(A): Evaluating Innovative Children’s Mental Health Services; Community Support Program - Mental Health Systems Improvement Demonstration Grants for Consumer and Family Networks; Cooperative Agreements for Employment Intervention Demonstration Program; National Consumer Technical Assistance Centers

561: Comprehensive Community Mental Health Services for Children with Serious Emotional Disturbances

1707(d)(1): Minority Health

1935(b)(1)(C): Evaluations of Substance Abuse Data Activities

1948(a): Provision of Technical Assistance to States, Public or Nonprofit Private Entities Receiving Funding Under the Community Mental Health Services and Substance Abuse Prevention and Treatment Block Grants

P.L. 100-690, Sec. 4231: Urban Alcohol and Substance Abuse

Sec. 511: Indian Urban Mental Health

42 USC 290aa: Public Health Service Act

Title V Substance Abuse and Mental health Services Administration

Sec. 501 (m)(n)

42 USC 290cc-11: Projects for Transition From Homelessness (PATH)

42 USC 290bb-31: Protection and Advocacy for Individuals with Mental Illness (PAIMI)

2. Purpose and Use of Information

SAMHSA’s financial assistance program evaluates the information provided by the applicants to select the ones most likely to meet program objectives and to determine that satisfactory progress is being made on funded projects.

Changes

Deleted the Program Narrative.

3. Use of Improved Technology

The Checklist is available in a fillable and printable .pdf form, which is downloaded as part of the grant application. The form is submitted electronically through the Grants.gov portal. In addition, Grants.gov will deliver the application to the agency.

Every effort is made to hold to a minimum the burden imposed on applicants and recipients. 

4. Efforts to Identify Duplication

No other application forms are authorized for the covered programs. No other similar information is available.

5. Involvement of Small Entities

The information requested is the minimum amount needed to meet program requirements. It cannot be reduced for small entities.

6. Consequences if Information is Collected Less Frequently

If this information is not collected, the programs will not have adequate data to ensure application type, completeness and manage communications with applicants and with recipient organizations. Reduced frequency is not possible as the annual frequency of applications and awards coincides with the annual appropriation of funds. Information is collected once as needed. There are no legal obstacles to reduce the burden.

7. Consistency with the Guidelines in 5 CFR 1320.5(d)(2)

These supplements fully comply with the guidelines at 5 CFR 1320.5(d)(2).

8. Consultation Outside of the Agency

A. The 60-Day Federal Register Notice was published in the Federal Register on March 8, 2017 (82 FR 12984). There were no public comments.

9. Payments to Respondents

There are no payments or gifts to the respondents.

10. Assurance of Confidentiality

No assurance of confidentiality is given.

11. Questions of a Sensitive Nature

No questions of a sensitive nature are asked.

12. Estimates of Annualized Burden Hours and Costs

A. Annualized Burden Hours

A. Program Checklist: The total response burden for the SAMHSA Supplement to the Application for Federal Assistance is 800.7hours. The burden was calculated on the basis of the estimated number of applications received for the covered programs. Applications are requested annually. In consultation with the SAMHSA Officer of Financial Resources and Centers, an estimate of .2 to .5 hours was established for the information required to complete the Program Narrative and Checklist.

The programs requiring the use of the HHS Checklist and Program Narrative and the estimated number of applicants per year are listed below.

SAMHSA Programs No. Of Applications

Assisted Outpatient Treatment 5

Block Grants for Community Mental Health Services 59

Block Grants for Prevention and Treatment of Substance Abuse 60

Comprehensive Community Mental Health Services for Children with Serious E 49

Drug-Free Communities Support Program Grants 686

Mental Health Disaster Assistance and Emergency Mental Health 7

PPHF- Cooperative Agreements to Implement the National Strategy for Suicide Prevention

4

Projects for Assistance in Transition from Homelessness (PATH) 56

Protection and Advocacy for Individuals with Mental Illness 57

Section 223 Demonstration Programs to Improve Community Mental Health Services

8

Substance Abuse and Mental Health Services: Projects of Regional and

National Significance 1,678

Total: 2,669

Forms	No. Of Respondents	Response per Respondent	Avg. Burden Per Response (in hours)	Total Burden (in hours)	Hourly Wage Cost	Total Wage Cost
Program Checklist	2,669	1	.3	801	$38.10	$30,507

B. Annualized Cost to the Respondent

Program Narrative and Checklist (SAMHSA):

SAMHSA estimates that respondents can complete the required narrative and checklist in an average of 4 hours. Salaries are estimated at $25/hour plus an additional $13/hour for fringe benefits and overhead.

Salary/fringe cost of $38.10/hr. x .3 hours = $11.43 per application. $152 x 2,669 respondents annually = $30,507 per year.

Total Annual Cost to Respondents

$30,507 (SAMHSA Checklist)

13. Estimates of Annualized Respondent Capital and Maintenance Costs

There are no capital or maintenance costs.

14. Estimates of Annualized Cost-Government

The annualized costs to the government is 30,507.

The third-party notification constitutes no cost to the Government.

15. Changes in Hour Burden

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.

16. Time Schedule, Publication, and Analysis Plans

These are recurring data collections, and collections are done on an as needed basis. Each Federal assistance program within SAMHSA has different time-lines for the receipt and processing of their applications. Data is not collected for statistical use. There are no current plans to publish any information received from this application process.

17. Expiration Date Display Exemption

The expiration date will be displayed.

18. Exceptions to Certification

This submission describing data collection requests no exceptions to the Certificate for Paperwork Reduction Act (5 CFR 1320).

B. Collections of Information Employing Statistical Methods

This information will not be used for statistical purposes.

List of Attachments

Attachment A SAMHSA Checklist SF-5161

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