National Mental Health Study (NMHS) Field Test

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Interview Verifica Interview Verification Script	Form and Instruction	New	Available
Form Screening Verifica Screening Verification Script	Form and Instruction	New	Available
Form CRS Parent Questio CRS Parent Questionnaire	Form and Instruction	New	Available
Form CRS Adult and Adol CRS Adult and Adolescents Questioonaire	Form and Instruction	New	Available
Form Parent Questionnai Parent Questionnaire	Form and Instruction	New	Available
Form In-Person Intervie In-Person Interview	Form and Instruction	New	Available
Form Screening Question Screening Questions	Form and Instruction	New	Available
NMHS OMB Supporting Statements A 7.12.17.docx	Supporting Statement A	Uploaded 2017-07-12	Available
NMHS OMB Supporting Statements B 7.11.17.docx	Supporting Statement B	Uploaded 2017-07-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
227432	Interview Verification	Form and Instruction	New	Interview Verification Script
227431	Screening Verification	Form and Instruction	New	Screening Verification Script
227430	Clinical Parent Interview	Form and Instruction	New	CRS Parent Questionnaire
227429	Clinical Interview	Form and Instruction	New	CRS Adult and Adolescents Questioonaire
227428	Parent Interview	Form and Instruction	New	Parent Questionnaire
227427	In-Person Interview	Form and Instruction	New	In-Person Interview
227426	Household Screening	Form and Instruction	New	Screening Questions

ICR Details

OMB Control No: 0930-0380	ICR Reference No: 201707-0930-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: National Mental Health Study (NMHS) Field Test
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: 09/29/2017
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/12/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2020	36 Months From Approved
Responses	4,263	0	0
Time Burden (Hours)	1,795	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The NMHS Field Test will evaluate the feasibility of conducting a full-scale national household, area probability mental health study designed to achieve three main goals: 1) estimate the prevalence of a number of specific mental disorders; 2) investigate correlates of mental health problems and patterns of care; and 3) provide a platform for follow-up studies on subgroups of interest.

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Authorizing Statute(s): US Code: 42 USC 505 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 20900	05/04/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 32006	07/11/2017
Did the Agency receive public comments on this ICR? Yes

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

table that charts list of burden

IC Title	Form No.	Form Name
Clinical Interview	CRS Adult and Adolescents Questioonaire	CRS Adult and Adolescents Questioonaire
Clinical Parent Interview	CRS Parent Questionnaire	CRS Parent Questionnaire
Household Screening	Screening Questions	Screening Questions
In-Person Interview	In-Person Interview	In-Person Interview
Interview Verification	Interview Verification Script	Interview Verification Script
Parent Interview	Parent Questionnaire	Parent Questionnaire
Screening Verification	Screening Verification Script	Screening Verification Script

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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	4,263	0	0	4,263	0	0
Annual Time Burden (Hours)	1,795	0	0	1,795	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, one-time data collection.

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Annual Cost to Federal Government: $2,464,020

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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: 07/12/2017

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