Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Service Provider F Service Provider Feedback Form	Form	Modified	Available
Form Child/YOuth Assess Child/YOuth Assessment and Referral Tool	Form	Modified	Available
Form Adult Assessment a Adult Assessment and Referral Tool	Form	Modified	Available
Form Weekly Tally Sheet Weekly Talkly Sheet	Form	Modified	Available
Form Group Encounter Lo Group Encounter Log	Form	Modified	Available
Form Individual/Family Individual/Family Encounter Log	Form	Modified	Available
Form Service Provider F Service Provider Feedback Form	Form and Instruction	Modified	Available
Form Participant Feedba Participant Feedback Form	Form and Instruction	Modified	Available
Form Participant_Feedba Participant_Feedback_Form	Form and Instruction	Modified	Repair queued
Form Child Assessment a Child Assessment and Referral Tool	Form and Instruction	Modified	Available
Form Adult Assessment a Adult Assessment and Referral Tool	Form and Instruction	Modified	Available
Form Weekly Tally Sheet Weekly Tally Sheet	Form and Instruction	Modified	Available
Form Group Encounter Lo Group Encounter Log	Form and Instruction	Modified	Available
CCP Data OMB SS-B 1.29.19.DOCX	Supporting Statement B	Uploaded 2019-01-29	Available
CCP Data SS Passback-Clean SUB_071619.docx	Supporting Statement A	Uploaded 2019-07-18	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Service Provider Feedback Form
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Child/YOuth Assessment and Referral Tool
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Adult Assessment and Referral Tool
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Weekly Talkly Sheet
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Group Encounter Log
7686	Individual/Family Crisis Counseling Servies Encounter Log	Form	Modified	Individual/Family Encounter Log
201612	Service Provider Feedback Form	Form and Instruction	Modified	Service Provider Feedback Form
201611	Participant Feedback Form	Form and Instruction	Modified	Participant Feedback Form
201611	Participant Feedback Form	Form and Instruction	Modified	Participant_Feedback_Form
201610	Assessment and Referral Tool	Form and Instruction	Modified	Child Assessment and Referral Tool
201610	Assessment and Referral Tool	Form and Instruction	Modified	Adult Assessment and Referral Tool
201609	Weekly Tally Sheet	Form and Instruction	Modified	Weekly Tally Sheet
201608	Group Encounter Log	Form and Instruction	Modified	Group Encounter Log

ICR Details

OMB Control No: 0930-0270	ICR Reference No: 201901-0930-004
Status: Historical Active	Previous ICR Reference No: 201507-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)
Type of Information Collection: Reinstatement without change of a previously approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 07/19/2019
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/31/2019
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2022	36 Months From Approved
Responses	159,062	0	0
Time Burden (Hours)	16,206	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: Data collection about services delivered and users of the services will be collected from the CCPs through standardized information tools which will then be reported to SAMHSA for appropriate processing and analysis. CCPs will be required to use the tools for data collection throughout the life of the program.

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Authorizing Statute(s): US Code: 42 USC 501 Name of Law: SAMHSA
  

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:
	83 FR 55733	11/07/2018
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 788	01/31/2019
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
Assessment and Referral Tool	Adult Assessment and Referral Tool, Child Assessment and Referral Tool	Adult Assessment and Referral Tool ,   Child Assessment and Referral Tool
Group Encounter Log	Group Encounter Log	Group Encounter Log
Individual/Family Crisis Counseling Servies Encounter Log	Individual/Family Encounter Log, Group Encounter Log, Weekly Tally Sheet, Adult Assessment and Referral Tool , Child/YOuth Assessment and Referral Tool, Service Provider Feedback Form	Individual/Family Encounter Log ,   Group Encounter Log ,   Weekly Talkly Sheet ,   Adult Assessment and Referral Tool ,   Child/YOuth Assessment and Referral Tool ,   Service Provider Feedback Form
Participant Feedback Form	Participant Feedback Form, Participant_Feedback_Form	Participant_Feedback_Form ,   Participant Feedback Form
Service Provider Feedback Form	Service Provider Feedback Form	Service Provider Feedback Form
Weekly Tally Sheet	Weekly Tally Sheet	Weekly Tally Sheet

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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	159,062	0	0	159,062	0	0
Annual Time Burden (Hours)	16,206	0	0	16,206	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 reinstatement.

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Annual Cost to Federal Government: $64,934

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: 01/31/2019

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