Recovery Serices for Adolescents and Families (RSAF)

Forms and Documents

Document Name	Status
Form Support Services S RSAF - Support Services Supervisor Form and Instruction	Modified
Form Family Program Cli RSAF - Family Program Clinician Form and Instruction	Modified
Form Social Network Sit RSAF - Social Network Site Moderator Form and Instruction	Modified
Form Telephone Support RSAF - Telephone Support Volunteer Form and Instruction	Modified
Form Project Coordinato RSAF - Project Coordinator Form and Instruction	Modified
Form Collateral Instrum RSAF - Collateral Form and Instruction	Modified
Form Adolescent Instrum RSAF - Adolescent Form and Instruction	Modified
OMB_Supporting_Statement_4.doc Supporting Statement B	2010-03-02
Project Coordinator Other Attachments.zip Supplementary Document	2010-03-02
OMB_Supporting_Statement_4.doc Supporting Statement A	2010-03-02

IC Document Collections

IC ID	Document Title	Status
191562	RSAF - Support Services Supervisor Form and Instruction	Modified
191561	RSAF - Family Program Clinician Form and Instruction	Modified
191560	RSAF - Social Network Site Moderator Form and Instruction	Modified
191559	RSAF - Telephone Support Volunteer Form and Instruction	Modified
191558	RSAF - Project Coordinator Form and Instruction	Modified
191557	RSAF - Collateral Form and Instruction	Modified
191556	RSAF - Adolescent Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0311	ICR Reference No: 201003-0930-002
Status: Historical Active	Previous ICR Reference No: 200912-0930-003
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Recovery Serices for Adolescents and Families (RSAF)
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 04/08/2010
	Date Received in OIRA: 03/16/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	04/30/2013	36 Months From Approved
Responses	21,506	0	0
Time Burden (Hours)	6,558	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: There are 28 data collection forms that will be used for gathering baseline and clinical data, monitoring preliminary outcomes, and monitoring implementation of the project's recovery support services. Adolescent participants will be asked to complete 3 forms, and collateral participants (parent/guardians) will be asked to complete 6 forms. Staff (consisting of Project Coordinators, Telephone Support Volunteers, Social Networking Site Moderators, Family Support Clinicians, and Support Services Supervisors) will be asked to complete 19 unique forms, with no individual completing more than 7 forms.

---

Authorizing Statute(s): US Code: 5 USC 501 Name of Law: SAMHSA
  

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:
	74 FR 22936	05/15/2009
30-day Notice:	Federal Register Citation:	Citation Date:
	74 FR 59549	11/18/2009
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 7

IC Title	Form No.	Form Name
RSAF - Adolescent	Adolescent Instruments	Adolescent Instruments
RSAF - Collateral	Collateral Instruments	Collateral Instruments
RSAF - Project Coordinator	Project Coordinator Instruments	Project Coordinator Instruments
RSAF - Telephone Support Volunteer	Telephone Support Volunteer	Telephone Support Volunteer
RSAF - Social Network Site Moderator	Social Network Site Moderator	Social Network Site Moderator
RSAF - Family Program Clinician	Family Program Clinician Instruments	Family Program Clinician Instruments
RSAF - Support Services Supervisor	Support Services Supervisor Instruments	Support Services Supervisor Instruments

---

ICR Summary 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	21,506	0	0	21,506	0	0
Annual Time Burden (Hours)	6,558	0	0	6,558	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.

---

Annual Cost to Federal Government: $1,197,336

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

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: 03/15/2010

---