Disaster Technical Assistance Center Disaster Mental Health Needs Assessment and Customer Satisfaction Survey

Forms and Documents

Document Name	Status
Form Cust Sat Survey e-Communications Recipient Form and Instruction	New
Form State/Territory DB DBHNA (State/Territory) Form and Instruction	New
Form Local Provider Ver DBHNA (Local Provider) Form and Instruction	New
Form Cust Sat Survey TA Requestor Form and Instruction	New
SAMHSA DTAC Supporting Statement_060611_FINAL.doc Supporting Statement B	2011-06-06
A.3 DBHNAS_FINAL.docx Supplementary Document	2011-03-29
B.2 Cust Sat Email Invitation_FINAL.docx Supplementary Document	2011-03-29
SAMHSA DTAC Supporting Statement_060611_FINAL.doc Supporting Statement A	2011-06-06

IC Document Collections

IC ID	Document Title	Status
197113	e-Communications Recipient Form and Instruction	New
197112	DBHNA (State/Territory) Form and Instruction	New
197111	DBHNA (Local Provider) Form and Instruction	New
197110	TA Requestor Form and Instruction	New

ICR Details

OMB Control No: 0930-0325	ICR Reference No: 201103-0930-004
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Disaster Technical Assistance Center Disaster Mental Health Needs Assessment and Customer Satisfaction Survey
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: 06/06/2011
	Date Received in OIRA: 03/30/2011
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	06/30/2014	36 Months From Approved
Responses	677	0	0
Time Burden (Hours)	253	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: The National Response Framework (NRF), establishes the framework for a comprehensive, national, "all-hazards" approach to domestic incident response. The NRF outlines how communities, States, the Federal Government, and private-sector and nongovernmental partners will work together in a coordinated fashion to plan for and develop comprehensive response plans for all types of emergency events. This data collection efforts will provide feedback on the overall effectiveness of SAMHSA Disaster Technical Assistance Center's (DTAC) services, ongoing needs at the national level, and areas that require enhanced Technical Assistance (TA) services.

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Authorizing Statute(s): US Code: 42 USC 501 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:
	76 FR 2698	01/14/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 17142	03/28/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
TA Requestor	Cust Sat Survey	Cust Sat Survey
DBHNA (Local Provider)	Local Provider Version DBHNAS	Local Provider Version DBHNAS
DBHNA (State/Territory)	State/Territory DBHNAS	State/Territory DBHNAS
e-Communications Recipient	Cust Sat Survey	Cust Sat Survey

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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	677	0	0	677	0	0
Annual Time Burden (Hours)	253	0	0	253	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: $184,000

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: 03/30/2011

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