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 Individual/Family Individual/Family Services Encounter Log	Form and Instruction	Modified	Available
Form Individual/Family Individual/Family Crisis Counseling Services Encounter Log	Form and Instruction	Modified	Repair queued
Form Service Provider F Service Provider Feedback Form	Form and Instruction	Modified	Available
Form Service Provider F Service Provider Feedback Form	Form and Instruction	Modified	Repair queued
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 Adult Assessment a Assessment and Referral Tool	Form and Instruction	Modified	Repair queued
Form Weekly Tally Sheet Weekly Tally Sheet	Form and Instruction	Modified	Available
Form Weekly Tally Sheet Weekly Tally Sheet	Form and Instruction	Modified	Repair queued
Form Group Encounter Lo Group Encounter Log	Form and Instruction	Modified	Available
Form Group Encounter Lo Group Encounter Log	Form and Instruction	Modified	Repair queued
2022 OMB CCP Data Supporting Statement B (SSB)_final_2022-01-12-clean.docx	Supporting Statement B	Uploaded 2022-06-29	Repair queued
2022 OMB CCP Data Supporting Statement A (SSA)_final_2022-06-30-clean.docx	Supporting Statement A	Uploaded 2022-07-01	Repair queued

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0930-0270	ICR Reference No: 202206-0930-002
Status: Historical Active	Previous ICR Reference No: 201901-0930-004
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Toolkit Protocol for the Crisis Counseling Assistance and Training Program (CCP)
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 08/08/2022
Retrieve Notice of Action (NOA)	Date Received in OIRA: 07/01/2022
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	08/31/2025	36 Months From Approved	08/31/2022
Responses	404,750	0	159,062
Time Burden (Hours)	38,969	0	16,206
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:
	87 FR 19959	04/22/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 38768	06/29/2022
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 Services Encounter Log	Individual/Family Services Encounter Log	Individual/Family Services Encounter Log
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	404,750	159,062	0	245,688	0	0
Annual Time Burden (Hours)	38,969	16,206	0	22,763	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: SAMHSA CMHS is requesting a change in burden (i.e., decrease in time to complete forms, but increase in the number of persons completing the forms) due to the surge in the number of CCP grants per year as well as the number of staff and participants associated with those programs. The burden will increase from previously approved 16,206 total burden hours to 38,959 in aggregate.

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Annual Cost to Federal Government: $71,532

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? No

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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: 07/01/2022

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