Certified Community Behavioral Health Clinic-Expansion (CCBHC-E)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Consumer Family Me Consumer/Grantee/Clinic Interviews	Form and Instruction	New	Repair queued
Form GPO Interview Prot GPO Interview	Form and Instruction	New	Repair queued
Form Grantee Survey Rou Grantee Survey	Form and Instruction	New	Missing upstream
Form Parents Caregiver Focus Groups	Form and Instruction	New	Missing upstream
Form Client Interview Client Interview	Form and Instruction	New	Repair queued
CCBHC-E CSE OMB Package - Supporting Statement A.docx	Supporting Statement A	Uploaded 2024-12-13	Repair queued
Attachment K3 Parent Caregiver of Youth Client Focus Group Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment J3 Youth Client Focus Group Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment I3 Adult Client Focus Group Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment H3 Clinic Partner Organization Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment G3 Clinic Staff Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment F3 Clinic Leadership Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment E3 Grantee Project Director Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment D3 Consumer and Family Member Organization Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment C3 GPO Interview Introduction Script.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment I4 Focus Group Sign-In Sheet.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment F5 Site Visit Schedule.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment F4 Site visit email communications.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment C4 Interview email communications.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment A2 Grantee Web Survey Reminder Email.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment K2 Parent Caregiver of Youth Client Focus Group Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment L2 Client Wellness Interview Questions SAMPLE Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment J2a Youth Client Focus Group Parental Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment J2 Youth Client Focus Group Assent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment I2 Adult Client Focus Group Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment H2 Clinic Partner Organization Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment G2 Clinic Staff Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment F2 Clinic Leadership Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Missing upstream
Attachment E2 Grantee Project Director Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment D2 Consumer and Family Member Organization Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
Attachment C2 GPO Interview Consent.docx	Supplementary Document	Uploaded 2024-12-13	Repair queued
CCBHC-E CSE OMB Package - Supporting Statement B.docx	Supporting Statement B	Uploaded 2024-12-13	Repair queued

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
273027	Consumer/Grantee/Clinic Interviews	Form and Instruction	New
273020	GPO Interview	Form and Instruction	New
273019	Grantee Survey	Form and Instruction	New
273018	Focus Groups	Form and Instruction	New
273017	Client Interview	Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202412-0930-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Certified Community Behavioral Health Clinic-Expansion (CCBHC-E)
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: 12/13/2024

table that charts list comparision

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	139,794	0
Time Burden (Hours)	36,820	0
Cost Burden (Dollars)	0	0

---

Abstract: SAMHSA is requesting clearance for eleven data collection instruments and forms related to the implementation and impact studies to be conducted as part of the evaluation. The evaluation will provide new information about how grants support adoption of the CCBHC model, how grants influence sustainable expansion of CCBHC capacities beyond the grant period, and how implementation of the model influences client-level outcomes. An evaluation of the IA and PDI grantees specifically provides an opportunity to examine implementation successes and challenges within each area of the certification criteria among a larger and more diverse group of clinics operating in different state and community contexts. By carefully measuring that context and how it changes over time, the evaluation can provide new information about how factors such as alternative sources of funding and state/community support for the model can influence implementation and outcomes. Finally, this evaluation has an opportunity to assess changes in quality of care and longitudinal client-level health, behavioral health, and functional outcomes.

---

Authorizing Statute(s): None

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 66427	08/15/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 10102	12/13/2024
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 5

table that charts list of burden

IC Title	Form No.	Form Name
Client Interview	Client Interview	Client Interview
Consumer/Grantee/Clinic Interviews	Clinic Leadership Interview Protocol, Consumer Family Member Organization Interview, Grantee Project Director Interview Protocol, Clinic Staff Interview Protocol, Clinic Partner Organization Interview Protocol	Consumer Family Member Organization Interview ,   Grantee Project Director Interview Protocol ,   Clinic Leadership Interview Protocol ,   Clinic Staff Interview Protocol ,   Clinic Partner Organization Interview Protocol
Focus Groups	Parents Caregiver of Youth Focus Group, Youth Client Focus Group, Adult Client Focus Group	Parents Caregiver of Youth Focus Group ,   Youth Client Focus Group ,   Adult Client Focus Group
GPO Interview	GPO Interview Protocol	GPO Interview Protocol
Grantee Survey	Grantee Survey Round 1, Grantee Survey Round 2	Grantee Survey Round 1 ,   Grantee Survey Round 2

---

ICR Summary of Burden

table that charts list 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	139,794	0	0	139,794	0	0
Annual Time Burden (Hours)	36,820	0	0	36,820	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 Information Collection Request so there is not a change in burden.

---

Annual Cost to Federal Government: $1,838,131

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

---

Common Form ICR:  No

---

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: 12/13/2024

---