Mental Health Block Grant Ten Percent Set Aside Evaluation

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Possible Admin. Da Possible Admin. Data Elements	Form and Instruction	New	Available
Form Fidelity Interview Fidelity Interview	Form and Instruction	New	Available
Form State MH Authority State MH Authority Interview	Form and Instruction	New	Available
Form CSC Participant In CSC Participant Interview	Form and Instruction	New	Available
Form CSC Staff Intervie CSC Staff Interview	Form and Instruction	New	Available
Form Agency Director/Ad Agency Director/Administrator Interview	Form and Instruction	New	Available
Form Site Survey Site Survey	Form and Instruction	New	Available
OMB_Supporting_Statement_A 6-19-17.docx	Supporting Statement A	Uploaded 2017-06-19	Available
OMB_Supporting_Statement_B 6-15-17.docx	Supporting Statement B	Uploaded 2017-06-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227222	Possible Admin. Data Elements	Form and Instruction	New
227221	Fidelity Interview	Form and Instruction	New
227220	State MH Authority Interview	Form and Instruction	New
227219	CSC Participant Interview	Form and Instruction	New
227218	CSC Staff Interview	Form and Instruction	New
227217	Agency Director/Administrator Interview	Form and Instruction	New
227216	Site Survey	Form and Instruction	New

ICR Details

OMB Control No: 0930-0376	ICR Reference No: 201706-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Mental Health Block Grant Ten Percent Set Aside 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: 08/08/2017
	Date Received in OIRA: 06/21/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2020	36 Months From Approved
Responses	1,498	0	0
Time Burden (Hours)	4,658	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The purpose of this 3-year evaluation is to assess the relationship between fidelity of selected coordinated specialty care (CSC) programs supported with Mental Health Block Grant (MHBG) Ten Percent Set Aside funding and participant outcomes. There are approximately 250 sites implementing CSC programs with MHBG ten percent set aside funding. All 250 sites will be asked to report on their implementation through an online survey. Up to 32 CSC sites across the nation will be recruited to participate in a process and outcome evaluation.

---

Authorizing Statute(s): US Code: 42 USC 520A Name of Law: Priority Mental Health Needs of the Regional and National Significance
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 17670	04/12/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 28332	06/21/2017
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

table that charts list of burden

IC Title	Form No.	Form Name
Site Survey	Site Survey	Site Survey
Agency Director/Administrator Interview	Agency Director/Administrator Interview	Agency Director/Administrator Interview
CSC Staff Interview	CSC Staff Interview	CSC Staff Interview
CSC Participant Interview	CSC Participant Interview	CSC Participant Interview
State MH Authority Interview	State MH Authority Interview	State MH Authority Interview
Fidelity Interview	Fidelity Interview	Fidelity Interview
Possible Admin. Data Elements	Possible Admin. Data Elements	Possible Admin. Data Elements

---

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	1,498	0	0	1,498	0	0
Annual Time Burden (Hours)	4,658	0	0	4,658	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.

---

Annual Cost to Federal Government: $732,344

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

---

Common Form ICR:  No

---

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: 06/21/2017

---