National Resource Center for Mental Health Promotion and Youth Violence Prevention

Forms and Documents

Document Name	Status
Form Case Study Intervi Case Study Interview Form and Instruction	New
Form Annual Performance Annual Performance Survey Form and Instruction	New
Form Site Visit Assessm Site Visit Assessment Survey Form and Instruction	New
Form Site Visit Assessm Site Visit Assessment Inteview Form and Instruction	New
Form Needs Assessment Needs Assessment Survey Form and Instruction	New
Form Needs Assessment Needs Assessment Focus Groups Form and Instruction	New
NRC OMB Supporting Statement Part A 3.15.17.docx Supporting Statement A	2017-03-15
NRC OMB Supporting Statement Part B 3.13.17.docx Supporting Statement B	2017-03-13

IC Document Collections

IC ID	Document Title	Status
226043	Case Study Interview Form and Instruction	New
226042	Annual Performance Survey Form and Instruction	New
226041	Site Visit Assessment Survey Form and Instruction	New
226040	Site Visit Assessment Inteview Form and Instruction	New
226039	Needs Assessment Survey Form and Instruction	New
226038	Needs Assessment Focus Groups Form and Instruction	New

ICR Details

OMB Control No: 0930-0374	ICR Reference No: 201703-0930-003
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: National Resource Center for Mental Health Promotion and Youth Violence Prevention
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: 05/18/2017
	Date Received in OIRA: 03/15/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2020	36 Months From Approved
Responses	340	0	0
Time Burden (Hours)	180	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The NRC will collect the information needed to conduct the annual assessment of NRC training and technical assistance activities for the SS/HS and Project LAUNCH programs, as well as the field-at-large. There are four instruments included in this package for approval: 1) Needs Assessment, 2) Site Visit Assessment, 3) Annual Performance Assessment, and 4) Case Study Interview.

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Authorizing Statute(s): US Code: 42 USC 505 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:
	81 FR 89122	12/09/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12982	03/08/2017
Did the Agency receive public comments on this ICR? No

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

IC Title	Form No.	Form Name
Needs Assessment Survey	Needs Assessment	Needs Assessment
Needs Assessment Focus Groups	Needs Assessment	Needs Assessment
Site Visit Assessment Inteview	Site Visit Assessment	Site Visit Assessment
Site Visit Assessment Survey	Site Visit Assessment	Site Visit Assessment
Annual Performance Survey	Annual Performance Assessment	Annual Performance Assessment
Case Study Interview	Case Study Interviews	Case Study Interviews

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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	340	0	0	340	0	0
Annual Time Burden (Hours)	180	0	0	180	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: $550,000

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: 03/15/2017

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