Zero Suicide Evaluation

Forms and Documents

Document Name	Status
Form Prevention Strateg Project Evaluator Form and Instruction	New
Form Consumer Study Int Clinicians/Providers Form and Instruction	New
Form Training Utilizati Healthcare Organization Staff Form and Instruction	New
Form Behavioral Health Grantee/Healthcare Organization Administrator Form and Instruction	New
Form Consumer Study Int Consumer Form and Instruction	New
ZS_SSA 11.21.24.docx Supporting Statement A	2024-11-21
Att N. Public Law 114-255.pdf Supplementary Document	2024-11-21
Att M. 2023-2026 samhsa-strategic-plan.pdf Supplementary Document	2024-11-21
Att A. PublicHealthServiceAct_AmendedFebruary2024.pdf Supplementary Document	2024-11-21

IC Document Collections

IC ID	Document Title	Status
272545	Project Evaluator Form and Instruction	New
272542	Clinicians/Providers Form and Instruction	New
272541	Healthcare Organization Staff Form and Instruction	New
272540	Grantee/Healthcare Organization Administrator Form and Instruction	New
272538	Consumer Form and Instruction	New

ICR Details

OMB Control No:	ICR Reference No: 202411-0930-003
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Zero Suicide Evaluation
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 11/22/2024

	Requested	Previously Approved
Expiration Date	36 Months From Approved
Responses	74,696	0
Time Burden (Hours)	20,520	0
Cost Burden (Dollars)	0	0

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Abstract: Zero Suicide is a commitment to suicide prevention in health and behavioral health care systems and a framework with a specific set of tools and strategies. It proposes that suicide deaths for individuals under care within health and behavioral health systems are preventable, and that a systematic approach to quality improvement in these settings is both available and necessary to identify suicidal patients and keep them safe. The Zero Suicide Evaluation is designed to assess the implementation and outcomes of SAMHSA’s Zero Suicide Program. Specifically, the Zero Suicide Evaluation will gather information about health system implementation of the Zero Suicide model, including staff training; health care provider training, knowledge, practices, and confidence related to implementing the core elements of the Zero Suicide model; consumer experiences with services provided under the Zero Suicide model; and outcomes related to suicide attempts and deaths.

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Authorizing Statute(s): US Code: 42 USC 290bb-43 Name of Law: Public Health Service Act (PHSA)
  

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:
	89 FR 73666	09/11/2024
30-day Notice:	Federal Register Citation:	Citation Date:
	89 FR 91775	11/20/2024
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
Clinicians/Providers	Consumer Study Interest Form	Consumer Study Interest Form
Consumer	Consumer Study Interest Form, Consumer Key Informant Interview, Consumer Experience Survey	Consumer Study Interest Form ,   Consumer Key Informant Interview ,   Consumer Experience Survey
Grantee/Healthcare Organization Administrator	Behavioral Health Provider Survey, Key Informant Interview Case Study, Key Informant Interview Cost Study	Behavioral Health Provider Survey ,   Key Informant Interview Case Study ,   Key Informant Interview Cost Study
Healthcare Organization Staff	Training Utilization and Preservation 6/12 month, Training Utilization and Preservation Baseline, Key Informant Interview Case Study, Workforce Survey	Training Utilization and Preservation 6/12 month ,   Training Utilization and Preservation Baseline ,   Key Informant Interview Case Study ,   Workforce Survey
Project Evaluator	Prevention Strategies Inventory, Training Activity Summary Page	Prevention Strategies Inventory ,   Training Activity Summary Page

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ICR Summary of Burden

	Total Request	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	74,696	0	0	74,696	0	0
Annual Time Burden (Hours)	20,520	0	0	20,520	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 collection.

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Annual Cost to Federal Government: $3,023,033

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

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     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? No

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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: 11/22/2024

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