National Center of Excellence for Infant and Early Childhood Mental Health Consultation

Forms and Documents

Document Name	Status
Form Annual Quarterly B Annual and Quarterly Benchmark Data Collection Form Form and Instruction	New
Form Cumulative Assessm Cumulative Services Assessment Form Form and Instruction	New
Form Technical Assistan T/A Follow-up Form Form and Instruction	New
Form Training Follow-up Training Follow-up Form Form and Instruction	New
Form Training Feedback Training Feedback Form Form and Instruction	New
Form Service Pre-Assess Service Pre-Assessment Form Form and Instruction	New
IECMHC_OMB Supporting Statement_Part B_10-7-16.docx Supporting Statement B	2016-10-07
IECMHC_OMB Supporting Statement_Part A_10-7-16.doc Supporting Statement A	2016-10-07

IC Document Collections

IC ID	Document Title	Status
223875	Annual and Quarterly Benchmark Data Collection Form Form and Instruction	New
223874	Cumulative Services Assessment Form Form and Instruction	New
223873	T/A Follow-up Form Form and Instruction	New
223872	Training Follow-up Form Form and Instruction	New
223871	Training Feedback Form Form and Instruction	New
223870	Service Pre-Assessment Form Form and Instruction	New

ICR Details

OMB Control No: 0930-0368	ICR Reference No: 201610-0930-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: National Center of Excellence for Infant and Early Childhood Mental Health Consultation
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: 01/23/2017
	Date Received in OIRA: 10/13/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2020	36 Months From Approved
Responses	2,285	0	0
Time Burden (Hours)	475	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: The National Center of Excellence (CoE) for Infant and Early Childhood Mental Health Consultation (IECMHC), a new program to advance the implementation of high-quality infant and early childhood mental health consultation across the nation through the development of tools, resources, training, technical assistance, and collaborative public and private partnerships. Its primary goals will be to promote the healthy social and emotional development of infants and young children and to prevent mental, emotional and behavioral disorders within this age group. Major activities for the CoE include convening a national expert workgroup and to lead the workgroup in developing a state-of-the-art Toolkit of the latest research and best practices for IECMHC (e.g., training, implementation, evaluation and financing) for early childhood settings, including early care and education and home visiting programs. The CoE will also create a dissemination and training plan for the Toolkit, and provide intensive training and technical assistance to states and tribes to help them build their capacity to implement, fund and evaluate IECMHC efforts successfully.

---

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

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:
	81 FR 49684	07/28/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 69070	10/05/2016
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 6

IC Title	Form No.	Form Name
Training Feedback Form	Training Feedback Form	Training Feedback Form
Annual and Quarterly Benchmark Data Collection Form	Annual Quarterly Benchmark Data Collection Forms	Annual Quarterly Benchmark Data Collection Forms
Service Pre-Assessment Form	Service Pre-Assessment Form	Service Pre-Assessment Form
Training Follow-up Form	Training Follow-up Form	Training Follow-up Form
T/A Follow-up Form	Technical Assistance Follow-up Form	Technical Assistance Follow-up Form
Cumulative Services Assessment Form	Cumulative Assessment	Cumulative Assessment

---

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	2,285	0	0	2,285	0	0
Annual Time Burden (Hours)	475	0	0	475	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: $79,145

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

---

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: 10/13/2016

---