“Talk. They Hear You.”: Use of “Screen 4 Success” Instruments and Consent form

Forms and Documents

Document Name	Status
Form S4S Informed Assen S4S Informed Assent for Youth Form and Instruction	New
Form S4S Informed Conse S4S Informed Consent for Parent Form and Instruction	New
Form S4S Screener S4S Screener Form and Instruction	New
S4S Supporting Statement A (SSA) _ 1.19.2022.docx Supporting Statement A	2022-07-08

IC Document Collections

IC ID	Document Title	Status
254544	S4S Informed Assent for Youth Form and Instruction	New
254543	S4S Informed Consent for Parent Form and Instruction	New
254542	S4S Screener Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202207-0930-001
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: “Talk. They Hear You.”: Use of “Screen 4 Success” Instruments and Consent form
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 07/08/2022

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	300,000	0
Time Burden (Hours)	38,000	0
Cost Burden (Dollars)	0	0

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Abstract: The “Screen 4 Success” (S4S) app and the screening tool elicit programmatic information that demonstrates aggregate impact at the program level. S4S may be the first access to screening for users and minors since the app provides a mechanism for users to self-screen anonymously, without being connected to services where screening might otherwise take place. The items collected are necessary to provide users with a self-screening tool for wellbeing, family environment, substance use, behavioral and physical health problems, provide information for self-referrals and assess “Talk. They Hear You.” national media campaign performance.

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Authorizing Statute(s): None

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 23188	04/19/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	87 FR 40854	07/08/2022
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
S4S Informed Assent for Youth	S4S Informed Assent for Youth	S4S Informed Assent for Youth
S4S Informed Consent for Parent	S4S Informed Consent for Parent	S4S Informed Consent for Parent
S4S Screener	S4S Screener	S4S Screener

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ICR Summary of Burden

	Total Request	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	300,000	0	0	300,000	0	0
Annual Time Burden (Hours)	38,000	0	0	38,000	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.

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Annual Cost to Federal Government: $607,758

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? 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: 07/08/2022

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