Evaluation of the SAMHSA Naloxone Education and Distribution Program

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Key Informant Selection Tool	Form	New	Available
Recruitment Contact Script	Form and Instruction	New	Available
ATT_H_SAMHSA&CDC_Naloxone_MOU_Signed.pdf	Supplementary Document	Uploaded 2018-03-15	Available
Att_C - IRB Doc.pdf	Supplementary Document	Uploaded 2017-11-29	Available
Att_B_60 Day FRN - 17AMP_Naloxone.pdf	Supplementary Document	Uploaded 2017-11-29	Available
Att_A_ Authorizing Legislation.docx	Supplementary Document	Uploaded 2017-11-29	Available
SSB_17AMP_Naloxone Eval_101017.docx	Supporting Statement B	Uploaded 2017-11-29	Available
SSA_17AMP_030718.docx	Supporting Statement A	Uploaded 2018-03-15	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
229205	Key Informant Selection Tool	Form	New
229204	Recruitment Contact Script	Form and Instruction	New
229203	Interview Guide for Laypersons	Other-Interview guide	New
229200	Interview Guide for Partners	Other-Interview guide	New
229198	Interview Guide for Grantees	Other-Interview Guide	New
229195	Focus Group Discussion Guide	Other-Discussion guide	New

ICR Details

OMB Control No: 0920-1222	ICR Reference No: 201711-0920-017
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-17AMP
Title: Evaluation of the SAMHSA Naloxone Education and Distribution Program
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 with change	Conclusion Date: 03/26/2018
	Date Received in OIRA: 12/19/2017
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2021	36 Months From Approved
Responses	580	0	0
Time Burden (Hours)	381	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: To evaluate the Substance Abuse and Mental Health Services Administration (SAMHSA) Grants to Prevent Prescription Drug/Opioid Overdose-Related Deaths. This evaluation will seek to describe and understand the scope and impact of the program on overdose.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

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 32704	07/17/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 60199	12/19/2017
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 6

table that charts list of burden

IC Title	Form No.	Form Name
Focus Group Discussion Guide
Interview Guide for Partners
Interview Guide for Laypersons
Recruitment Contact Script	none	Recruitment contact script
Key Informant Selection Tool	none	Key Informant Selection Tool
Interview Guide for Grantees

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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	580	0	0	580	0	0
Annual Time Burden (Hours)	381	0	0	381	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 ICR.

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Annual Cost to Federal Government: $565,851

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

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: 12/19/2017

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