Staff Sergeant Parker Gordon Fox - Suicide Prevention Grant Program (SSG Fox SPGP)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 10-317d SSG Fox SPGP - Program Exit Checklist & Assessments	Form	Modified	Available
Form 10-317d SSG Fox SPGP - Program Exit Checklist	Form	Modified	Repair queued
Form 10-317c SSG Fox SPGP - Participant Satisfaction Survey	Form	Modified	Available
Form 10-317c SSG Fox SPGP - Participant Satisfaction Survey	Form	Modified	Repair queued
Form 10-317b SSG Fox SPGP - Intake Form & Assessments	Form and Instruction	Modified	Available
Form 10-317b SSG Fox SPGP - Intake Form & Assessments	Form and Instruction	Modified	Repair queued
Form 10-317a SSG Fox SPGP - Eligibility Screening Form	Form	Modified	Available
Form 10-317a SSG Fox SPGP - Eligibility Screening	Form	Modified	Repair queued
Form 10-316f SSG Fox SPGP - Quarterly Grantee Financial Report	Form and Instruction	Modified	Available
Form 10-316f SSG Fox SPGP - Other Grantee Financial Report	Form and Instruction	Modified	Repair queued
Form 10-316e SSG Fox SPGP - Annual Grantee Financial Report	Form and Instruction	Modified	Available
Form 10-316e SSG Fox SPGP - Annual Grantee Financial Report	Form and Instruction	Modified	Repair queued
Form 10-316d SSG Fox SPGP - Corrective Action Plan (CAP)	Form and Instruction	Modified	Available
Form 10-316d SSG Fox SPGP - Corrective Action Plan (CAP)	Form and Instruction	Modified	Repair queued
Form 10-316c SSG Fox SPGP - Program Change Request	Form	Modified	Available
Form 10-316c SSG Fox SPGP - Program Change Request	Form	Modified	Repair queued
Form 10-316b SSG Fox SPGP - Other Grantee Performance Report	Form	Modified	Available
Form 10-316b SSG Fox SPGP - Other Grantee Performance Report	Form	Modified	Repair queued
Form 10-316a SSG Fox SPGP - Annual Grantee Performance Report	Form	Modified	Repair queued
Form 10-316a SSG Fox SPGP - Annual Grantee Performance Report	Form	Modified	Repair queued
Form 10-315b SSG Fox SPGP - Renewal Application	Form and Instruction	Modified	Available
Form 10-315b SSG Fox SPGP - Renewal Application	Form and Instruction	Modified	Repair queued
Form 10-315a SSG Fox SPGP - Application	Form and Instruction	Modified	Available
Form 10-315a SSG Fox SPGP - Application	Form and Instruction	Modified	Repair queued
30-day FRN_2900-0904_SSG Fox Suicide Prevention Grant Program (SPGP)_published 01202023.pdf	Supplementary Document	Uploaded 2023-01-20	Repair queued
60-day FRN_2900-0904_SSG Fox Suicide Prevention Grant Program (SPGP)_published 11082022.pdf	Supplementary Document	Uploaded 2023-01-12	Repair queued
Short Warwick Edinburgh Mental Well Being Scale (SWEMWS).pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
Socio Economic Status (SES).pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
Patient Health Questionnaire (PHQ9).pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
Interpersonal Support Evaluation List (ISEL-12).pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
Generalized Self-Efficacy Scale.pdf	Supplementary Document	Uploaded 2022-04-28	Repair queued
Supporting Statement A_2900-0904_SSG Fox Suicide Prevention Grant Program (SPGP)_updated Jan 2023.docx	Supporting Statement A	Uploaded 2023-01-20	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
253146	SSG Fox SPGP - Program Exit Checklist	Form	Modified	SSG Fox SPGP - Program Exit Checklist & Assessments
253146	SSG Fox SPGP - Program Exit Checklist	Form	Modified
253145	SSG Fox SPGP - Columbia Suicide Risk Screening (CSSRS)	Other-Screening Tool	Modified
253144	SSG Fox SPGP - Participant Satisfaction Survey	Form	Modified	SSG Fox SPGP - Participant Satisfaction Survey
253144	SSG Fox SPGP - Participant Satisfaction Survey	Form	Modified
253143	SSG Fox SPGP - Intake Form & Assessments	Form and Instruction	Modified	SSG Fox SPGP - Intake Form & Assessments
253143	SSG Fox SPGP - Intake Form & Assessments	Form and Instruction	Modified
253142	SSG Fox SPGP - Eligibility Screening	Form	Modified	SSG Fox SPGP - Eligibility Screening Form
253142	SSG Fox SPGP - Eligibility Screening	Form	Modified
253141	SSG Fox SPGP - Other Grantee Financial Report	Form and Instruction	Modified	SSG Fox SPGP - Quarterly Grantee Financial Report
253141	SSG Fox SPGP - Other Grantee Financial Report	Form and Instruction	Modified
253140	SSG Fox SPGP - Annual Grantee Financial Report	Form and Instruction	Modified	SSG Fox SPGP - Annual Grantee Financial Report
253140	SSG Fox SPGP - Annual Grantee Financial Report	Form and Instruction	Modified
253139	SSG Fox SPGP - Corrective Action Plan (CAP)	Form and Instruction	Modified	SSG Fox SPGP - Corrective Action Plan (CAP)
253139	SSG Fox SPGP - Corrective Action Plan (CAP)	Form and Instruction	Modified
253138	SSG Fox SPGP - Program Change Request	Form	Modified	SSG Fox SPGP - Program Change Request
253138	SSG Fox SPGP - Program Change Request	Form	Modified
253136	SSG Fox SPGP - Other Grantee Performance Report	Form	Modified	SSG Fox SPGP - Other Grantee Performance Report
253136	SSG Fox SPGP - Other Grantee Performance Report	Form	Modified
253133	SSG Fox SPGP - Annual Grantee Performance Report	Form	Modified	SSG Fox SPGP - Annual Grantee Performance Report
253133	SSG Fox SPGP - Annual Grantee Performance Report	Form	Modified
253131	SSG Fox SPGP - Renewal Application	Form and Instruction	Modified	SSG Fox SPGP - Renewal Application
253131	SSG Fox SPGP - Renewal Application	Form and Instruction	Modified
253128	SSG Fox SPGP - Application	Form and Instruction	Modified	SSG Fox SPGP - Application
253128	SSG Fox SPGP - Application	Form and Instruction	Modified

ICR Details

OMB Control No: 2900-0904	ICR Reference No: 202210-2900-015
Status: Historical Active	Previous ICR Reference No: 202203-2900-009
Agency/Subagency: VA	Agency Tracking No: 2900-0904
Title: Staff Sergeant Parker Gordon Fox - Suicide Prevention Grant Program (SSG Fox SPGP)
Type of Information Collection: Extension without change of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/07/2023
Retrieve Notice of Action (NOA)	Date Received in OIRA: 01/20/2023
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2026	36 Months From Approved	03/31/2023
Responses	30,205	0	30,205
Time Burden (Hours)	21,827	0	21,827
Cost Burden (Dollars)	0	0	0

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Abstract: In order to award grants under the Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program, and assess services and compliance with grants provided, VA will require submission of Applications for grants and Renewals of grants, Eligibility Screening Tools, Suicide Risk Screening Tools, Participant Satisfaction Surveys, Intake Form and Program Exit Checklist (which each utilize the same five standardized assessment tools required for baseline mental health screening, as listed below) and Compliance Reports.

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Authorizing Statute(s): US Code: 38 USC 1720F Name of Law: Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program
  

Citations for New Statutory Requirements: US Code: 38 USC 1720F Name of Law: Commander John Scott Hannon Veterans Mental Health Care Improvement Act of 2019

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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 67536	11/08/2022
30-day Notice:	Federal Register Citation:	Citation Date:
	88 FR 3779	01/20/2023
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 13

table that charts list of burden

IC Title	Form No.	Form Name
SSG Fox SPGP - Annual Grantee Financial Report	10-316e	SSG Fox SPGP - Annual Grantee Financial Report
SSG Fox SPGP - Annual Grantee Performance Report	10-316a	SSG Fox SPGP - Annual Grantee Performance Report
SSG Fox SPGP - Application	10-315a	SSG Fox SPGP - Application
SSG Fox SPGP - Columbia Suicide Risk Screening (CSSRS)
SSG Fox SPGP - Corrective Action Plan (CAP)	10-316d	SSG Fox SPGP - Corrective Action Plan (CAP)
SSG Fox SPGP - Eligibility Screening	10-317a	SSG Fox SPGP - Eligibility Screening Form
SSG Fox SPGP - Intake Form & Assessments	10-317b	SSG Fox SPGP - Intake Form & Assessments
SSG Fox SPGP - Other Grantee Financial Report	10-316f	SSG Fox SPGP - Quarterly Grantee Financial Report
SSG Fox SPGP - Other Grantee Performance Report	10-316b	SSG Fox SPGP - Other Grantee Performance Report
SSG Fox SPGP - Participant Satisfaction Survey	10-317c	SSG Fox SPGP - Participant Satisfaction Survey
SSG Fox SPGP - Program Change Request	10-316c	SSG Fox SPGP - Program Change Request
SSG Fox SPGP - Program Exit Checklist	10-317d	SSG Fox SPGP - Program Exit Checklist & Assessments
SSG Fox SPGP - Renewal Application	10-315b	SSG Fox SPGP - Renewal Application

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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	30,205	30,205	0	0	0	0
Annual Time Burden (Hours)	21,827	21,827	0	0	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

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Annual Cost to Federal Government: $144,796

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.     Yes

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.     Yes

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: 01/20/2023

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