Assessment of the Underage Drinking Prevention Education Initiatives State/Territory Videos Project

Forms and Documents

Document Name	Status
Form Attachment 3 Viewers Feedback Form Form and Instruction	New
Form Dissemination Upda Dissemination Update Form Form and Instruction	New
Form Interview Form Interview Form Form and Instruction	New
OMB Supporting Statement_B.doc Supporting Statement B	2011-08-09
Attachment 6_State-Territory Videos Project_Communications Sent Prior to Assessment.pdf Supplementary Document	2011-08-09
Attachment 5_ICF Macro IRB Review Findings Form_State-Territory Videos Project.pdf Supplementary Document	2011-08-09
Attachment 4_Report on UAD Prevention Videos A Four-State Pilot Project.pdf Supplementary Document	2011-08-09
OMB Supporting Statement_UADPEI State-Territory Videos Project-10.28.11.doc Supporting Statement A	2011-10-28

IC Document Collections

IC ID	Document Title	Status
198963	Viewers Feedback Form Form and Instruction	New
198962	Dissemination Update Form Form and Instruction	New
198961	Interview Form Form and Instruction	New

ICR Details

OMB Control No: 0930-0331	ICR Reference No: 201108-0930-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/SAMHSA	Agency Tracking No:
Title: Assessment of the Underage Drinking Prevention Education Initiatives State/Territory Videos Project
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: 10/30/2011
	Date Received in OIRA: 08/22/2011
Terms of Clearance: For the initial POC feedback form (attachment 1), SAMHSA changed the collection mode from interview to online. The agency also reduced the number of questions from 31 to 25, achieved more neutral language on several questions, and revised the burden estimate. For the follow-up POC feedback form (attachment 2), SAMHSA reduced the number of questions and updated the consent form. For the viewer feedback form (attachment 3), SAMHSA reduced the number of questions from 16 to 10 and revised nearly every question to simplify and decrease burden. SAMHSA also added a child consent question.

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2014	36 Months From Approved
Responses	3,128	0	0
Time Burden (Hours)	268	0	0
Cost Burden (Dollars)	0	0	0

---

Abstract: SAMHSA/CSAP intends to support the production of the State/Territory UAD prevention videos annually. The information collected will be used by SAMHSA/CSAP to 1) ascertain whether the videos produced under the State/Territory Videos project are assisting States and Territories in communicating effectively about their UAD prevention initiatives, goals, and objectives; 2) document the dissemination efforts of the videos; and 3) enhance the TA that is provided by the video production team in producing the videos.

---

Authorizing Statute(s): US Code: 42 USC 515 Name of Law: CSAP
  

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:
	76 FR 25359	05/04/2011
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 44341	07/25/2011
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 3

IC Title	Form No.	Form Name
Interview Form	Interview Form	Interview form
Dissemination Update Form	Dissemination Update Form	Dissemination Update Form
Viewers Feedback Form	Attachment 3	Video Viewers Feedback Form

---

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	3,128	0	0	3,128	0	0
Annual Time Burden (Hours)	268	0	0	268	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: $46,689

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: 08/22/2011

---