Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)

Forms and Documents

Document Name	Status
Form Privacy Pledge Stakeholder Survey Form	New
Form Client Interview_6 6 month Followup Form	New
Form Client Interview_B Baseline Form	New
CSAT GBHI OMB Supporting Statement FINAL_3_16_11.doc Supporting Statement B	2011-03-16
Attachment 7_Stakeholder Survey Consent Form.doc Supplementary Document	2010-12-17
Attachment 1_SAMHSA Priority Goals.doc Supplementary Document	2010-12-17
Attachment 8_Privacy Pledge.doc Supplementary Document	2010-12-17
Attachment 6_Client Interview Consent Form.doc Supplementary Document	2010-12-17
Attachment 5_Client Interview Script.doc Supplementary Document	2010-12-17
CSAT GBHI OMB Supporting Statement FINAL_3_16_11.doc Supporting Statement A	2011-03-16

IC Document Collections

IC ID	Document Title	Status
195856	Stakeholder Survey Form	New
195855	6 month Followup Form	New
195854	Baseline Form	New

ICR Details

OMB Control No: 0930-0320	ICR Reference No: 201012-0930-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Cross-Site Evaluation for the Benefit of Homeless Individuals (GBHI)
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 with change	Conclusion Date: 03/16/2011
	Date Received in OIRA: 12/30/2010
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2014	36 Months From Approved
Responses	11,241	0	0
Time Burden (Hours)	4,006	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The information collected through all three surveys (Baseline and 6-month Followup, and Stakeholder Survey) will provide the data necessary to conduct a complete structure, process, outcome, and cost evaluation. The data collected through the Stakeholder Survey will provide descriptive information about stakeholders involved with the CSAT GBHI grant program and their relationship with the grantee program.

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Authorizing Statute(s): US Code: 5 USC 290 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:
	75 FR 45123	08/02/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	75 FR 79011	12/17/2010
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
Stakeholder Survey	Privacy Pledge	Privacy Pledge
Baseline	Client Interview_Baseline	Client Interview_Baseline
6 month Followup	Client Interview_6Month	Client Interview_6Month

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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	11,241	0	0	11,241	0	0
Annual Time Burden (Hours)	4,006	0	0	4,006	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: $65,305

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]? 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? Uncollected

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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: 12/30/2010

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