Participant Feedback Forms for the Mental Health Care Provider Education (MHCPE) in the HIV/AIDS Program

Forms and Documents

Document Name	Status
Form All IC Forms Session Report Form Form and Instruction	Modified
Form Forms in IC-1 Ethics Participant Feedback Form Form and Instruction	Modified
Form Forms in IC-1 Adherence Participant Feedback Form Form and Instruction	Modified
Form Forms in IC-1 Neuropsychiatric Participant Feedback Form and Instruction	Modified
Form Forms in IC-1 Participant Feedback Form Form and Instruction	Modified
CMHS MHCPE SS_B 2.21.14.docx Supporting Statement B	2014-03-05
CMHS MHCPE SS-A 2.21.14.docx Supporting Statement A	2014-03-05

IC Document Collections

IC ID	Document Title	Status
7583	Session Report Form Form and Instruction	Modified
195853	Ethics Participant Feedback Form Form and Instruction	Modified
195852	Adherence Participant Feedback Form Form and Instruction	Modified
195851	Neuropsychiatric Participant Feedback Form and Instruction	Modified
195850	Participant Feedback Form Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0195	ICR Reference No: 201403-0930-002
Status: Historical Active	Previous ICR Reference No: 201012-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 21539
Title: Participant Feedback Forms for the Mental Health Care Provider Education (MHCPE) in the HIV/AIDS Program
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 05/29/2014
	Date Received in OIRA: 03/13/2014
Terms of Clearance: The agency will not collect social security numbers or partial social security numbers as part of this collection.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2017	36 Months From Approved	05/31/2014
Responses	12,600	0	12,600
Time Burden (Hours)	1,843	0	1,843
Cost Burden (Dollars)	0	0	0

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Abstract: These standardized forms will collect systematic feedback from trainees participating in the Minority HIV/AIDS Mental Health Treatment and Education Services Program and the Mental Health Care Provider Education in HIV/AIDS III Program. The overall goal of the two programs is to help create a cadre of traditional and non-traditional mental health service providers who utilize state-of-the-art information on the psychological and neuropsychological sequelae of HIV/AIDS, and to enhance the nation's ability to have an impact on the HIV/AIDS epidemic.

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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:
	78 FR 78374	12/26/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	79 FR 12206	03/04/2014
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Session Report Form	All IC Forms	All IC Forms
Participant Feedback Form	Forms in IC-1	Forms in IC-1
Neuropsychiatric Participant Feedback	Forms in IC-1	Forms in IC-1
Adherence Participant Feedback Form	Forms in IC-1	Forms in IC-1
Ethics Participant Feedback Form	Forms in IC-1	Forms in IC-1

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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	12,600	12,600	0	0	0	0
Annual Time Burden (Hours)	1,843	1,843	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: $395,000

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: 03/13/2014

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