Community Support Evaluation

Forms and Documents

Document Name	Status
Form ENFG Employment Sp Employment Specialists Form and Instruction	New
Form ENFG Employer Vers Hiring Managers Form and Instruction	New
Form SSA KII Service Pr SE Service Providers Form and Instruction	New
Form SSA KII Administra Administrators Form and Instruction	New
Form BPI SE Version Project Directors Form and Instruction	New
Form Concept Mapping Br BHTCC Stakeholders Form and Instruction	New
Form Comparison Study T Court Clerks Form and Instruction	New
Form SLA KII Consumer V Consumers Form and Instruction	New
Form SLA KII Service Pr BHTCC Service Providers Form and Instruction	New
Form SLA KII Court Pers Court Personnel Form and Instruction	New
Form BPI BHTCC Version Project Evaluators Form and Instruction	New
CSE SS Part A for SAMHSA_031116.docx Supporting Statement A	2016-03-11
CSE SS Part B FINAL_090816.docx Supporting Statement B	2016-09-21

IC Document Collections

IC ID	Document Title	Status
220576	Employment Specialists Form and Instruction	New
220575	Hiring Managers Form and Instruction	New
220574	SE Service Providers Form and Instruction	New
220572	Administrators Form and Instruction	New
220571	Project Directors Form and Instruction	New
220569	BHTCC Stakeholders Form and Instruction	New
220567	Court Clerks Form and Instruction	New
220566	Consumers Form and Instruction	New
220565	BHTCC Service Providers Form and Instruction	New
220564	Court Personnel Form and Instruction	New
220563	Project Evaluators Form and Instruction	New

ICR Details

OMB Control No: 0930-0363	ICR Reference No: 201603-0930-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Community Support Evaluation
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: 09/21/2016
	Date Received in OIRA: 03/11/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved
Responses	687	0	0
Time Burden (Hours)	561	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the CSE is to (1) describe and assess BHTCC and SE grantee activities and procedures, including the intermediate or direct effects of the programs on participants; (2) document the application and sanctioned adaptations of BHTCC programs in the justice system and of the SE Program; and (3) design and implement plans to disseminate knowledge about how to replicate effective projects in other States, territories, tribal nations, and communities.

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Authorizing Statute(s): US Code: 42 USC 290aa Name of Law: Data Collection
  

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:
	80 FR 79349	12/21/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 10641	03/01/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

IC Title	Form No.	Form Name
Administrators	SSA KII Administrator Version	SSA KII Administrator Version
SE Service Providers	SSA KII Service Provider Version	SSA KII Service Provider Version
Court Clerks	Comparison Study Tool (6 Month), Comparison Study Tool (Baseline)., Comparison Study Tool (18 Month)	Comparison Study Tool (Baseline). ,   Comparison Study Tool (18 Month) ,   Comparison Study Tool (6 Month)
Project Evaluators	BPI BHTCC Version, 18-Month Client-Level Abstraction Tool	BPI BHTCC Version ,   18-Month Client-Level Abstraction Tool
Court Personnel	SLA KII Court Personnel Version	SLA KII Court Personnel Version
Project Directors	BPI SE Version	BPI SE Version
BHTCC Stakeholders	Concept Mapping Brainstorming Activity, Concept Mapping Sorting and Rating Activity	Concept Mapping Brainstorming Activity ,   Concept Mapping Sorting and Rating Activity
Hiring Managers	ENFG Employer Version	ENFG Employer Version
Employment Specialists	ENFG Employment Specialist Version	ENFG Employment Specialist Version
BHTCC Service Providers	SLA KII Service Provider Version	SLA KII Service Provider Version
Consumers	SLA KII Consumer Version	SLA KII Consumer Version

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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	687	0	0	687	0	0
Annual Time Burden (Hours)	561	0	0	561	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: $1,674,392

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: 03/11/2016

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