Children’s Mental Health Initiative National Evaluation

Forms and Documents

Document Name	Status
Form Child and Family Child and Family Instruments Form and Instruction	New
Form Financial Benchmar Financial Planning Form and Instruction	New
Form Financial Mapping Benchmark Tool Form and Instruction	New
Form Financing Plan Sur Financial Mapping Interview Form and Instruction	New
Form Network Analysis S Network Analysis Survey Form and Instruction	New
Form System of Care Exp SOCESS Form and Instruction	New
Form Key Partner Interv Key Partner Interview Form and Instruction	New
CMHI OMB SS-B 2015 10.17.16.docx Supporting Statement B	2017-03-13
CMHI OMB SS-A 2015 12.22.16.docx Supporting Statement A	2017-03-13

IC Document Collections

IC ID	Document Title	Status
226027	Child and Family Instruments Form and Instruction	New
226026	Financial Planning Form and Instruction	New
226025	Benchmark Tool Form and Instruction	New
226024	Financial Mapping Interview Form and Instruction	New
226023	Network Analysis Survey Form and Instruction	New
226022	SOCESS Form and Instruction	New
226021	Key Partner Interview Form and Instruction	New

ICR Details

OMB Control No: 0930-0375	ICR Reference No: 201703-0930-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Children’s Mental Health Initiative National 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 without change	Conclusion Date: 06/01/2017
	Date Received in OIRA: 03/14/2017
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2020	36 Months From Approved
Responses	12,107	0	0
Time Burden (Hours)	4,330	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The purpose of the Children’s Mental Health Initiative (CMHI) National Evaluation is to assess the success of the CMHI grants in expanding and sustaining the reach of SOC values, principles, and practices. These include maximizing system-level coordination and planning, offering a comprehensive array of services, and prioritizing family and youth involvement. In order to obtain a clear picture of CMHI grant activities, this longitudinal, multi-level evaluation will measure activities and performance of grantees essential to building and sustaining effective Systems of Care (SOC)’s.

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Authorizing Statute(s): US Code: 42 USC 564 Name of Law: Aditional Provisions - Evaluations for Children
  

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 93946	12/22/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 12979	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: 7

IC Title	Form No.	Form Name
SOCESS	System of Care Expansion and Sustainability Survey	System of Care Expansion and Sustainability Survey
Network Analysis Survey	Network Analysis Survey	Network Analysis Survey
Financial Mapping Interview	Financing Plan Survey and Interviews	Financing Plan Survey and Interviews
Benchmark Tool	Financial Mapping Interview	Financial Mapping Interview
Financial Planning	Financial Benchmarking Tool	Financial Benchmarking Tool
Key Partner Interview	Key Partner Interviews	Key Partner Interviews
Child and Family Instruments	Child and Family	Child and Family

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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	12,107	0	0	12,107	0	0
Annual Time Burden (Hours)	4,330	0	0	4,330	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: $1,345,824

Does this IC contain surveys, censuses, or employ statistical methods? No

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: 03/14/2017

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