Monitoring of National Suicide Prevention Lifeline Form

Forms and Documents

Document Name	Status
Form Client Initial Scr Client Initial Script Form and Instruction	Modified
Form Client Follow-up I Client Follow-up Interview Refusal Form and Instruction	Modified
Form Client Follow-up C Client Follow-up Consent Script Refusal Form and Instruction	Modified
Form Client Initial Scr Client Initial Script Refusal Form and Instruction	Modified
Form Counselor Question Counselor Follow-up Questionnaire Form and Instruction	Modified
Form Attitudes Question MI/SP Counselor Attitudes Questionnaire Form and Instruction	Removed
Form Counselor Consent Counselor Consent Form and Instruction	Modified
Form Client Follow-up I Client Follow-up Interview Form and Instruction	Modified
Form Client Follow-up C Client Follow-up Consent Script Form and Instruction	Modified
NSPL Part A 6.21.16.docx Supporting Statement A	2016-06-21
NSPL Part B 031516.docx Supporting Statement B	2016-06-21

IC Document Collections

IC ID	Document Title	Status
7689	Client Initial Script Form and Instruction	Modified
207802	Client Follow-up Interview Refusal Form and Instruction	Modified
207801	Client Follow-up Consent Script Refusal Form and Instruction	Modified
207800	Client Initial Script Refusal Form and Instruction	Modified
205813	Counselor Follow-up Questionnaire Form and Instruction	Modified
205812	MI/SP Counselor Attitudes Questionnaire Form and Instruction	Removed
205811	Counselor Consent Form and Instruction	Modified
205810	Client Follow-up Interview Form and Instruction	Modified
205809	Client Follow-up Consent Script Form and Instruction	Modified

ICR Details

OMB Control No: 0930-0274	ICR Reference No: 201606-0930-003
Status: Historical Active	Previous ICR Reference No: 201302-0930-001
Agency/Subagency: HHS/SAMHSA	Agency Tracking No: 18805
Title: Monitoring of National Suicide Prevention Lifeline Form
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 09/21/2016
	Date Received in OIRA: 06/22/2016
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	09/30/2019	36 Months From Approved	09/30/2016
Responses	1,274	0	3,131
Time Burden (Hours)	262	0	649
Cost Burden (Dollars)	0	0	0

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Abstract: The National Suicide Prevention Lifeline--Call Monitoring Form collect information on the caller, the elements of a suicide risk assessment that are completed by the crisis worker, as well as what action plan that is developed with the caller and what referrals are provided to the caller. Additionally, the evaluation includes follow-up data collection utilizing the Crisis Hotline Telephone Follow-up Assessment. The purpose of this assessment is to collect data regarding: (1) suicide risk status at the time of and since the call, (2) depressive symptoms at follow-up, (3) service utilization since the call, (4) barriers to service access, and (5) the caller's perception of the efficacy of the hotline intervention.

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Authorizing Statute(s): US Code: 42 USC 520A Name of Law: Priority Mental Health Needs of Regional and National Significance
  

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 22622	04/18/2016
30-day Notice:	Federal Register Citation:	Citation Date:
	81 FR 40337	06/21/2016
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 8

IC Title	Form No.	Form Name
Client Follow-up Consent Script Refusal	Client Follow-up Consent Script	Client Follow-up Consent Script
Client Follow-up Interview Refusal	Client Follow-up Interview	Client Follow-up Interview
Client Initial Script	Client Initial Script	Client Initial Script
Client Follow-up Consent Script	Client Follow-up Consent Script	Client Follow-up Consent Script
Client Follow-up Interview	Client Follow-up Interview	Client Follow-up Interview
Counselor Consent	Counselor Consent	Counselor Consent
Counselor Follow-up Questionnaire	Counselor Questionnaire	Counselor Questionnaire
Client Initial Script Refusal	Client Initial Script	Client Initial Script
MI/SP Counselor Attitudes Questionnaire	Attitudes Questionnaire	Attitudes Questionnaire

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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	1,274	3,131	0	-1,857	0	0
Annual Time Burden (Hours)	262	649	0	-387	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Currently there are 649 total burden hours in the OMB inventory. SAMHSA is requesting 264 hours for this revision, representing a decrease of 403 annual burden hours. This change in burden is the result of a program change where the number of participating crisis centers has decreased and the one data collection form has been eliminated.

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Annual Cost to Federal Government: $280,694

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: 06/22/2016

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