Agency Information Collection Activities: Proposed Collection; Comment Request, 22936-22939 [E9-11377]
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Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices
estimated annualized burden hours are
5,932.
ESTIMATED ANNUALIZED BURDEN TABLE
Type of respondent
Form name
Core NAMCS Forms .............
Office-based physicians/CHC
providers.
Community Health Center
Directors.
Physician Induction Interview
(NAMCS–1).
Community Health Center Induction Interview
(NAMCS–201).
Patient Record form
(NAMCS–30).
Pulling, re-filing Patient
Record form (NAMCS–30).
Cervical Cancer Screening
Supplement (NAMCS–
CCS).
EMR/EHR Mail Survey .........
Physician Induction Interview
(NAMCS–1).
Patient Record form
(NAMCS–30).
Office-based physicians/CHC
providers/staff.
Office/CHC staff ....................
Office-based physicians/CHC
providers/staff.
Lab Values Pre-test Forms ...
Office-based physicians .......
Office-based physicians .......
Office-based physicians/staff
Maryam I. Daneshvar,
Acting Reports Clearance Officer, Office of
the Chief Science Officer, Centers for Disease
Control and Prevention.
[FR Doc. E9–11379 Filed 5–14–09; 8:45 am]
BILLING CODE 4163–18–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Substance Abuse and Mental Health
Services Administration
Agency Information Collection
Activities: Proposed Collection;
Comment Request
In compliance with Section
3506(c)(2)(A) of the Paperwork
Reduction Act of 1995 concerning
opportunity for public comment on
proposed collections of information, the
Substance Abuse and Mental Health
Services Administration (SAMHSA)
will publish periodic summaries of
proposed projects. To request more
information on the proposed projects or
to obtain a copy of the information
collection plans, call the SAMHSA
Reports Clearance Officer at (240) 276–
1243.
Comments are invited on: (a) Whether
the proposed collections of information
are necessary for the proper
performance of the functions of the
agency, including whether the
information shall have practical utility;
(b) the accuracy of the agency’s estimate
of the burden of the proposed collection
of information; (c) ways to enhance the
quality, utility, and clarity of the
information to be collected; and (d)
ways to minimize the burden of the
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collection of information on
respondents, including through the use
of automated collection techniques or
other forms of information technology.
Proposed Project: Recovery Services for
Adolescents and Families—New
The Substance Abuse and Mental
Health Services Administration’s
(SAMHSA) Center for Substance Abuse
Treatment will conduct a data collection
on the helpfulness of recovery support
services for young people and their
families after leaving substance abuse
treatment. Specifically, the Recovery
Services for Adolescents and Families
(RSAF) project is trying to understand
whether or not young people and their
families find the following recovery
support services helpful: (1) Telephone/
text message support; (2) a recoveryoriented social networking site; and (3)
a family program. Approximately 200
adolescent respondents will be asked to
complete 4 data collection forms (some
repeated) during 5 interviews (baseline
and 4 follow-ups) over a 12 month
period after enrollment or discharge
from treatment. Approximately 200
collateral respondents (i.e., a parent/
guardian/concerned other) will be asked
to complete 7 data collection forms
(some repeated) during 5 interviews
(baseline and 4 follow-ups) over a 12
month period after their adolescent’s
enrollment or discharge from treatment.
Approximately 15 to 20 project staff
respondents, including Project
Coordinators, Telephone Support
Volunteers, a Social Network Site
Moderator, Family Program Clinicians,
and a Support Services Supervisor, will
be asked to complete between 2 and 5
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Number of
responses per
respondent
Number of
respondents
Type of form
Hours per
response
3,657
1
28/60
104
1
20/60
738
30
9/60
650
30
1/60
464
1
15/60
1,143
23
1
1
20/60
28/60
8
30
9/60
data collection forms at varying
intervals during the delivery of recovery
support services. Across all
respondents, a total of 26 data collection
forms will be used. Depending on the
time interval and task, information
collections will take anywhere from
about 5 minutes to 2 hours to complete.
A description of each data collection
form follows:
Follow-Up Locator Form—Participant
(FLF–P; Adolescent Respondent). The
FLF–P contains over 50 items that are a
combination of yes/no, multiple choice,
and open-ended formats. Data are
gathered about an adolescent’s contact
information, personal contacts, criminal
justice contacts, school/job contacts,
hang-out information, internet contacts,
and identifying information in order to
locate and interview that adolescent
over multiple follow-up intervals.
Global Appraisal of Individual
Needs—Initial (GAIN–I 5.6.0 Full;
Adolescent Respondent). The GAIN is
an evidence-based assessment used with
both adolescents and adults and in
outpatient, intensive outpatient, partial
hospitalization, methadone, short-term
residential, long-term residential,
therapeutic community, and
correctional programs. There are over
1,000 questions in this initial version
that are in multiple formats, including
multiple choice, yes/no, and openended. Eight content areas are covered:
Background, Substance Use, Physical
Health, Risk Behaviors and Disease
Prevention, Mental and Emotional
Health, Environment and Living
Situation, Legal, and Vocational. Each
section contains questions on the
recency of problems, breadth of
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Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices
symptoms, and recent prevalence as
well as lifetime service utilization,
recency of utilization, and frequency of
recent utilization.
Global Appraisal of Individual
Needs—Monitoring 90 Days (GAIN–M90
5.6.0 Full; Adolescent Respondent). The
GAIN is an evidence-based assessment
used with both adolescents and adults
and in outpatient, intensive outpatient,
partial hospitalization, methadone,
short-term residential, long-term
residential, therapeutic community, and
correctional programs. There are over
500 questions in this follow-up version
that are in multiple formats, including
multiple choice, yes/no, and openended. Eight content areas are covered:
Background, Substance Use, Physical
Health, Risk Behaviors and Disease
Prevention, Mental and Emotional
Health, Environment and Living
Situation, Legal, and Vocational. Each
section contains questions on the
recency of problems, breadth of
symptoms, and recent prevalence as
well as lifetime service utilization,
recency of utilization, and frequency of
recent utilization.
Supplemental Assessment Form (SAF
0309; Adolescent Respondent). The SAF
contains 72 questions that are a
combination of multiple choice, yes/no,
and open-ended formats. Content areas
include: Race, happiness with parent or
caregiver in several life areas,
participation in prosocial activities,
receipt of and satisfaction with
telephone support services, and usage of
and satisfaction with the project’s social
networking site.
Follow-Up Locator Form—Collateral
(FLF–C; Collateral Respondent). The
FLF–C contains over 50 items that are
a combination of yes/no, multiple
choice, and open-ended formats. Data
are gathered about a collateral’s contact
information, personal contacts, and job
contacts in order to locate and interview
that collateral over multiple follow-up
intervals.
Global Appraisal of Individual
Needs—Collateral Monitoring (GCI;
Collateral Respondent). The GCI
contains over 200 items in this initial
version that are in multiple formats,
including multiple choice, yes/no, and
open-ended. The following content
areas are covered: Relationship to the
adolescent respondent, background, and
the adolescent’s background and
substance use, environment and living
situation, and vocational information.
There are questions on the recency of
problems, breadth of symptoms, and
recent prevalence as well as lifetime
service utilization, recency of
utilization, and frequency of recent
utilization.
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Global Appraisal of Individual
Needs—Collateral Monitoring (GCM
5.3.3; Collateral Respondent). The GCM
contains over 200 items in this followup version that are in multiple formats,
including multiple choice, yes/no, and
open-ended. The following content
areas are covered: Relationship to the
adolescent respondent, background, and
the adolescent’s background and
substance use, environment and living
situation, and vocational information.
There are questions on the recency of
problems, breadth of symptoms, and
recent prevalence as well as lifetime
service utilization, recency of
utilization, and frequency of recent
utilization.
Supplemental Assessment Form—
Collateral (SAF—Collateral; Collateral
Respondent). The SAF contains 72
questions that are a combination of
multiple choice, yes/no, and openended formats. Content areas include:
Knowledge about the adolescent’s
participation in prosocial activities,
receipt of and satisfaction with
telephone support services, and usage of
and satisfaction with the project’s social
networking site.
Self-Evaluation Questionnaire (SEQ;
Collateral Respondent). The SEQ
contains 40 multiple choice items that
ask the collateral about feelings and
symptoms of anxiety.
Family Environment Scale (FES;
Collateral Respondent). The FES
contains 18 yes/no items that measure
family cohesion and conflict.
Relationship Happiness Scale
(Caregiver Version) (Collateral
Respondent). The Relationship
Happiness Scale contains 8 items that
ask the collateral about happiness with
his/her relationship with the adolescent
respondent in various life areas.
Eligibility Checklist (Project
Coordinator). The Eligibility Checklist
contains 12 yes/no items that are used
to determine whether or not an
adolescent meets inclusion/exclusion
criteria for the project and is eligible to
be approached for informed consent.
Follow-Up Contact Log (Project
Coordinator). The Follow-Up Contact
Log is open-ended and provides space
for all data collected during attempted
and completed follow-up contacts, over
the phone and in-person, to be recorded.
Volunteer/Staff Survey (Project
Coordinator). The Volunteer/Staff
Survey contains 10 items in fill-in-theblank, yes/no, and multiple choice
formats. Items ask about background,
demographic information, and role in
the project.
Telephone Support Case Review Form
(Telephone Support Volunteer). The
Telephone Support Case Review Form
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22937
contains multiple rows that allow a
volunteer to record 5 pieces of data
about adolescents that they make phone
calls to: Initials, treatment discharge
status/date, weeks since treatment
discharge, date of last telephone session,
and number of completed telephone
sessions since discharge. This allows
the volunteer and supervisor to monitor
the progress of active cases.
Telephone Support Call Log
(Telephone Support Volunteer). The
Telephone Support Call Log is openended and provides space for all data
collected during attempted and
completed support contacts to be
recorded.
Adolescent Telephone Support
Documentation Form (Telephone
Support Volunteer). The Adolescent
Telephone Support Documentation
Form contains 22 items that are asked
of an adolescent during a telephone
support contact by a volunteer. The
form is used to record yes/no and openended responses to questions asking
about substance use and recoveryrelated activities.
Telephone Support Discharge Form
(Telephone Support Volunteer). The
Telephone Support Discharge Form
contains 10 fields to record the
following information at the end of an
adolescent’s participation in telephone
support: Adolescent name, today’s date,
volunteer name, notification date,
telephone support intake date,
telephone support discharge date,
reason for discharge, number of
completed sessions, referral for more
intervention, and successful contact for
more intervention.
Volunteer/Staff Survey (Telephone
Support Volunteer)—See Volunteer/
Staff Survey (Project Coordinator)
above.
Social Networking Moderator Log
(Social Network Site Moderator). The
Social Networking Moderator Log
contains 11 fields for the moderator to
record usage data for the project’s social
networking site. The moderator tracks
number of visits to the site, number of
unique visitors, messages posted, chat
room attendance, and problems with
users.
Volunteer/Staff Survey (Social
Network Site Moderator)—See
Volunteer/Staff Survey (Project
Coordinator) above.
Family Program Progress Notes
(Family Program Clinician). The Family
Program Progress Notes form is openended and provides space for all data
collected during attempted and
completed family program contacts to
be recorded.
Family Program Attendance Log
(Family Program Clinician). The Family
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Program Attendance Log is used to
record 6 pieces of information about
each attempted session: Session
number, scheduled date, was the
session rescheduled (yes/no), was the
family member a no-show (yes/no), did
the family member attend the session
(yes/no), and comments.
Family Program Case Review Report
(Family Program Clinician). The Family
Program Case Review Report contains
multiple rows that allow a clinician to
record information that allows the
clinician and supervisor to monitor the
progress of active cases. Areas asked
about include: Family program
procedures delivered, date of last
session, and weeks in family program.
Family Program Discharge Form
(Family Program Clinician). The Family
Program Discharge Form contains 9
fields to record the following
information at the end of participation
in the family program: Caregiver name,
today’s date, adolescent name,
notification date, clinician name, family
program intake date, family program
discharge date, reason for discharge, and
number of completed sessions.
Volunteer/Staff Survey (Family
Program Clinician)—See Volunteer/
Staff Survey (Project Coordinator)
above.
Adolescent Telephone Support
Quality Assurance Checklist (Support
Services Supervisor). This checklist
contains 43 items that ask the
supervisor to rate how well a telephone
support volunteer delivered required
service components to adolescents.
Volunteers are rated on a scale of 1
through 5 in the following areas:
Substance use since last call (no use),
substance use since last call (use),
substance use since last call (still using),
substance use since last call (stopped
using), attendance at 12-step meetings,
recovery-related activities, activities
related to global health, follow-up since
last call, closing the call, overall, general
clinical skills, and overall difficulty of
session.
Social Networking Quality Assurance
Checklist (Support Services Supervisor).
This checklist contains 17 items that ask
the supervisor to rate how well a social
networking site moderator delivered
required service components to
adolescents. The moderator is rated on
Number of respondents
Instrument/form
Responses
per respondent
a scale of 1 through 5 in the following
areas: Group discussions, administrative
tasks, overall, and general skills.
Family Program QA Checklist
(Support Services Supervisor). This
checklist contains 72 items that ask the
supervisor to rate how well a family
program clinician delivered required
service components to family members.
The clinician is rated on a scale of 1
through 5 in the following areas: Initial
meeting motivational strategies,
domestic violence precautions,
functional analysis of substance use,
positive communication skills, use of
positive reinforcement, time out from
positive reinforcement, allowing the
identified patient to experience the
natural consequences of substance use,
helping concerned significant others’
enrich their own lives, maintaining the
identified patient in recovery-oriented
systems of care, and general.
Volunteer/Staff Survey (Support
Services Supervisor)—See Volunteer/
Staff Survey (Project Coordinator)
above.
The following table is a list of the
hour burden of the information
collection by form and by respondent:
Total responses
Hours per response
Total
annualized hour
burden per respondent *
Adolescent Respondent
FLF–P ..............................................................................
GAIN–I 5.6.0 Full .............................................................
GAIN–M90 5.6.0 Full .......................................................
SAF ..................................................................................
200
200
200
200
1
1
4
5
200
200
800
1000
.32
2
1
.25
.32
2
4
1.25
Collateral (parent/guardian/concerned other) Respondent
FLF–C ..............................................................................
GCI ...................................................................................
GCM 5.3.3 ........................................................................
SAF–Collateral .................................................................
SEQ ..................................................................................
FES ..................................................................................
Relationship Happiness Scale (Caregiver) ......................
200
200
200
200
200
200
200
1
1
4
5
5
5
5
200
200
800
1000
1000
1000
1000
.25
.25
.25
.25
.16
.08
.08
.25
.25
1
1.25
.8
.4
.4
4
4
4
50
50
1
200
200
4
.25
.16
.25
12.5
8
.25
8
8
450
25
3600
200
.25
.16
112.5
4
8
8
8
450
25
1
3600
200
8
.5
.16
.25
225
4
.25
1
1
52
1
52
1
.5
.25
26
4
4
4
650
50
650
2600
200
2600
.16
.08
.25
104
4
162.5
Project Staff
Project Coordinator:
Eligibility Checklist ....................................................
Follow-Up Contact Log .............................................
Volunteer/Staff Survey ..............................................
Telephone Support Volunteer:
Telephone Support Case Review Form ...................
Telephone Support Call Log .....................................
Adolescent Telephone Support Documentation
Form ......................................................................
Telephone Support Discharge Form ........................
Volunteer/Staff Survey ..............................................
Social Network Site Moderator:
Social Networking Moderator Log ............................
Volunteer/Staff Survey ..............................................
Family Program Clinician:
Family Program Progress Notes ..............................
Family Program Attendance Log ..............................
Family Program Case Review Report ......................
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15MYN1
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Federal Register / Vol. 74, No. 93 / Friday, May 15, 2009 / Notices
Number of respondents
Instrument/form
Responses
per respondent
Total responses
Hours per response
Family Program Discharge Form .............................
Volunteer/Staff Survey ..............................................
Support Services Supervisor:
Adolescent Telephone Support QA Checklist ..........
Social Networking QA Checklist ...............................
Family Program QA Checklist ..................................
Volunteer/Staff Survey ..............................................
4
4
50
1
200
4
1
1
1
18
12
12
12
1
12
12
12
18
Column Total .....................................................
418
2580
........................
.16
.25
1
Total
annualized hour
burden per respondent *
8
.25
.5
1
.25
12
6
12
.25
..........................
713.67
* Total Annualized Hour Burden Per Respondent = Responses Per Respondent × Hours Per Response.
Send comments to Summer King,
SAMHSA Reports Clearance Officer,
Room 7–1044, 1 Choke Cherry Road,
Rockville, MD 20857 AND e-mail her a
copy at summer.king@samhsa.hhs.gov.
Written comments should be received
within 60 days of this notice.
Dated: May 11, 2009.
Elaine Parry,
Director, Office of Program Services.
[FR Doc. E9–11377 Filed 5–14–09; 8:45 am]
BILLING CODE 4162–20–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Substance Abuse and Mental Health
Services Administration
Current List of Laboratories Which
Meet Minimum Standards To Engage in
Urine Drug Testing for Federal
Agencies
AGENCY: Substance Abuse and Mental
Health Services Administration, HHS.
ACTION:
Notice.
SUMMARY: The Department of Health and
Human Services (HHS) notifies Federal
agencies of the laboratories currently
certified to meet the standards of
Subpart C of the Mandatory Guidelines
for Federal Workplace Drug Testing
Programs (Mandatory Guidelines). The
Mandatory Guidelines were first
published in the Federal Register on
April 11, 1988 (53 FR 11970), and
subsequently revised in the Federal
Register on June 9, 1994 (59 FR 29908),
on September 30, 1997 (62 FR 51118),
and on April 13, 2004 (69 FR 19644).
A notice listing all currently certified
laboratories is published in the Federal
Register during the first week of each
month. If any laboratory’s certification
is suspended or revoked, the laboratory
will be omitted from subsequent lists
until such time as it is restored to full
certification under the Mandatory
Guidelines.
VerDate Nov<24>2008
16:43 May 14, 2009
Jkt 217001
If any laboratory has withdrawn from
the HHS National Laboratory
Certification Program (NLCP) during the
past month, it will be listed at the end,
and will be omitted from the monthly
listing thereafter.
This notice is also available on the
Internet at https://
www.workplace.samhsa.gov and
https://www.drugfreeworkplace.gov.
FOR FURTHER INFORMATION CONTACT: Mrs.
Giselle Hersh, Division of Workplace
Programs, SAMHSA/CSAP, Room
2–1042, One Choke Cherry Road,
Rockville, Maryland 20857; 240–276–
2600 (voice), 240–276–2610 (fax).
SUPPLEMENTARY INFORMATION: The
Mandatory Guidelines were developed
in accordance with Executive Order
12564 and section 503 of Public Law
100–71. Subpart C of the Mandatory
Guidelines, ‘‘Certification of
Laboratories Engaged in Urine Drug
Testing for Federal Agencies,’’ sets strict
standards that laboratories must meet in
order to conduct drug and specimen
validity tests on urine specimens for
Federal agencies. To become certified,
an applicant laboratory must undergo
three rounds of performance testing plus
an on-site inspection. To maintain that
certification, a laboratory must
participate in a quarterly performance
testing program plus undergo periodic,
on-site inspections.
Laboratories which claim to be in the
applicant stage of certification are not to
be considered as meeting the minimum
requirements described in the HHS
Mandatory Guidelines. A laboratory
must have its letter of certification from
HHS/SAMHSA (formerly: HHS/NIDA)
which attests that it has met minimum
standards.
In accordance with Subpart C of the
Mandatory Guidelines dated April 13,
2004 (69 FR 19644), the following
laboratories meet the minimum
standards to conduct drug and specimen
validity tests on urine specimens:
ACL Laboratories, 8901 W. Lincoln
Ave., West Allis, WI 53227, 414–328–
PO 00000
Frm 00059
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7840/800–877–7016, (Formerly:
Bayshore Clinical Laboratory).
ACM Medical Laboratory, Inc., 160
Elmgrove Park, Rochester, NY 14624,
585–429–2264.
Advanced Toxicology Network, 3560
Air Center Cove, Suite 101, Memphis,
TN 38118, 901–794–5770/888–290–
1150.
Aegis Sciences Corporation, 345 Hill
Ave., Nashville, TN 37210, 615–255–
2400, (Formerly: Aegis Analytical
Laboratories, Inc.).
Baptist Medical Center-Toxicology
Laboratory, 9601 I–630, Exit 7, Little
Rock, AR 72205–7299, 501–202–2783,
(Formerly: Forensic Toxicology
Laboratory Baptist Medical Center).
Clendo Reference Laboratory, Avenue
Santa Cruz #58, Bayamon, Puerto Rico
00959, 787–620–9095.
Clinical Reference Lab, 8433 Quivira
Road, Lenexa, KS 66215–2802, 800–
445–6917.
Diagnostic Services, Inc., dba DSI,
12700 Westlinks Drive, Fort Myers,
FL 33913, 239–561–8200/800–735–
5416.
Doctors Laboratory, Inc., 2906 Julia
Drive, Valdosta, GA 31602, 229–671–
2281.
DrugScan, Inc., P.O. Box 2969, 1119
Mearns Road, Warminster, PA 18974,
215–674–9310.
DynaLIFE Dx,* 10150–102 St., Suite
200, Edmonton, Alberta, Canada T5J
5E2, 780–451–3702/800–661–9876,
(Formerly: Dynacare Kasper Medical
Laboratories).
ElSohly Laboratories, Inc., 5 Industrial
Park Drive, Oxford, MS 38655, 662–
236–2609.
Gamma-Dynacare Medical
Laboratories,* A Division of the
Gamma-Dynacare Laboratory
Partnership, 245 Pall Mall Street,
London, ONT, Canada N6A 1P4, 519–
679–1630.
Kroll Laboratory Specialists, Inc., 1111
Newton St., Gretna, LA 70053, 504–
361–8989/800–433–3823, (Formerly:
Laboratory Specialists, Inc.).
Kroll Laboratory Specialists, Inc., 450
Southlake Blvd., Richmond, VA
E:\FR\FM\15MYN1.SGM
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]]>Agencies
[Federal Register Volume 74, Number 93 (Friday, May 15, 2009)]
[Notices]
[Pages 22936-22939]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-11377]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Agency Information Collection Activities: Proposed Collection;
Comment Request
In compliance with Section 3506(c)(2)(A) of the Paperwork Reduction
Act of 1995 concerning opportunity for public comment on proposed
collections of information, the Substance Abuse and Mental Health
Services Administration (SAMHSA) will publish periodic summaries of
proposed projects. To request more information on the proposed projects
or to obtain a copy of the information collection plans, call the
SAMHSA Reports Clearance Officer at (240) 276-1243.
Comments are invited on: (a) Whether the proposed collections of
information are necessary for the proper performance of the functions
of the agency, including whether the information shall have practical
utility; (b) the accuracy of the agency's estimate of the burden of the
proposed collection of information; (c) ways to enhance the quality,
utility, and clarity of the information to be collected; and (d) ways
to minimize the burden of the collection of information on respondents,
including through the use of automated collection techniques or other
forms of information technology.
Proposed Project: Recovery Services for Adolescents and Families--New
The Substance Abuse and Mental Health Services Administration's
(SAMHSA) Center for Substance Abuse Treatment will conduct a data
collection on the helpfulness of recovery support services for young
people and their families after leaving substance abuse treatment.
Specifically, the Recovery Services for Adolescents and Families (RSAF)
project is trying to understand whether or not young people and their
families find the following recovery support services helpful: (1)
Telephone/text message support; (2) a recovery-oriented social
networking site; and (3) a family program. Approximately 200 adolescent
respondents will be asked to complete 4 data collection forms (some
repeated) during 5 interviews (baseline and 4 follow-ups) over a 12
month period after enrollment or discharge from treatment.
Approximately 200 collateral respondents (i.e., a parent/guardian/
concerned other) will be asked to complete 7 data collection forms
(some repeated) during 5 interviews (baseline and 4 follow-ups) over a
12 month period after their adolescent's enrollment or discharge from
treatment. Approximately 15 to 20 project staff respondents, including
Project Coordinators, Telephone Support Volunteers, a Social Network
Site Moderator, Family Program Clinicians, and a Support Services
Supervisor, will be asked to complete between 2 and 5 data collection
forms at varying intervals during the delivery of recovery support
services. Across all respondents, a total of 26 data collection forms
will be used. Depending on the time interval and task, information
collections will take anywhere from about 5 minutes to 2 hours to
complete. A description of each data collection form follows:
Follow-Up Locator Form--Participant (FLF-P; Adolescent Respondent).
The FLF-P contains over 50 items that are a combination of yes/no,
multiple choice, and open-ended formats. Data are gathered about an
adolescent's contact information, personal contacts, criminal justice
contacts, school/job contacts, hang-out information, internet contacts,
and identifying information in order to locate and interview that
adolescent over multiple follow-up intervals.
Global Appraisal of Individual Needs--Initial (GAIN-I 5.6.0 Full;
Adolescent Respondent). The GAIN is an evidence-based assessment used
with both adolescents and adults and in outpatient, intensive
outpatient, partial hospitalization, methadone, short-term residential,
long-term residential, therapeutic community, and correctional
programs. There are over 1,000 questions in this initial version that
are in multiple formats, including multiple choice, yes/no, and open-
ended. Eight content areas are covered: Background, Substance Use,
Physical Health, Risk Behaviors and Disease Prevention, Mental and
Emotional Health, Environment and Living Situation, Legal, and
Vocational. Each section contains questions on the recency of problems,
breadth of
[[Page 22937]]
symptoms, and recent prevalence as well as lifetime service
utilization, recency of utilization, and frequency of recent
utilization.
Global Appraisal of Individual Needs--Monitoring 90 Days (GAIN-M90
5.6.0 Full; Adolescent Respondent). The GAIN is an evidence-based
assessment used with both adolescents and adults and in outpatient,
intensive outpatient, partial hospitalization, methadone, short-term
residential, long-term residential, therapeutic community, and
correctional programs. There are over 500 questions in this follow-up
version that are in multiple formats, including multiple choice, yes/
no, and open-ended. Eight content areas are covered: Background,
Substance Use, Physical Health, Risk Behaviors and Disease Prevention,
Mental and Emotional Health, Environment and Living Situation, Legal,
and Vocational. Each section contains questions on the recency of
problems, breadth of symptoms, and recent prevalence as well as
lifetime service utilization, recency of utilization, and frequency of
recent utilization.
Supplemental Assessment Form (SAF 0309; Adolescent Respondent). The
SAF contains 72 questions that are a combination of multiple choice,
yes/no, and open-ended formats. Content areas include: Race, happiness
with parent or caregiver in several life areas, participation in
prosocial activities, receipt of and satisfaction with telephone
support services, and usage of and satisfaction with the project's
social networking site.
Follow-Up Locator Form--Collateral (FLF-C; Collateral Respondent).
The FLF-C contains over 50 items that are a combination of yes/no,
multiple choice, and open-ended formats. Data are gathered about a
collateral's contact information, personal contacts, and job contacts
in order to locate and interview that collateral over multiple follow-
up intervals.
Global Appraisal of Individual Needs--Collateral Monitoring (GCI;
Collateral Respondent). The GCI contains over 200 items in this initial
version that are in multiple formats, including multiple choice, yes/
no, and open-ended. The following content areas are covered:
Relationship to the adolescent respondent, background, and the
adolescent's background and substance use, environment and living
situation, and vocational information. There are questions on the
recency of problems, breadth of symptoms, and recent prevalence as well
as lifetime service utilization, recency of utilization, and frequency
of recent utilization.
Global Appraisal of Individual Needs--Collateral Monitoring (GCM
5.3.3; Collateral Respondent). The GCM contains over 200 items in this
follow-up version that are in multiple formats, including multiple
choice, yes/no, and open-ended. The following content areas are
covered: Relationship to the adolescent respondent, background, and the
adolescent's background and substance use, environment and living
situation, and vocational information. There are questions on the
recency of problems, breadth of symptoms, and recent prevalence as well
as lifetime service utilization, recency of utilization, and frequency
of recent utilization.
Supplemental Assessment Form--Collateral (SAF--Collateral;
Collateral Respondent). The SAF contains 72 questions that are a
combination of multiple choice, yes/no, and open-ended formats. Content
areas include: Knowledge about the adolescent's participation in
prosocial activities, receipt of and satisfaction with telephone
support services, and usage of and satisfaction with the project's
social networking site.
Self-Evaluation Questionnaire (SEQ; Collateral Respondent). The SEQ
contains 40 multiple choice items that ask the collateral about
feelings and symptoms of anxiety.
Family Environment Scale (FES; Collateral Respondent). The FES
contains 18 yes/no items that measure family cohesion and conflict.
Relationship Happiness Scale (Caregiver Version) (Collateral
Respondent). The Relationship Happiness Scale contains 8 items that ask
the collateral about happiness with his/her relationship with the
adolescent respondent in various life areas.
Eligibility Checklist (Project Coordinator). The Eligibility
Checklist contains 12 yes/no items that are used to determine whether
or not an adolescent meets inclusion/exclusion criteria for the project
and is eligible to be approached for informed consent.
Follow-Up Contact Log (Project Coordinator). The Follow-Up Contact
Log is open-ended and provides space for all data collected during
attempted and completed follow-up contacts, over the phone and in-
person, to be recorded.
Volunteer/Staff Survey (Project Coordinator). The Volunteer/Staff
Survey contains 10 items in fill-in-the-blank, yes/no, and multiple
choice formats. Items ask about background, demographic information,
and role in the project.
Telephone Support Case Review Form (Telephone Support Volunteer).
The Telephone Support Case Review Form contains multiple rows that
allow a volunteer to record 5 pieces of data about adolescents that
they make phone calls to: Initials, treatment discharge status/date,
weeks since treatment discharge, date of last telephone session, and
number of completed telephone sessions since discharge. This allows the
volunteer and supervisor to monitor the progress of active cases.
Telephone Support Call Log (Telephone Support Volunteer). The
Telephone Support Call Log is open-ended and provides space for all
data collected during attempted and completed support contacts to be
recorded.
Adolescent Telephone Support Documentation Form (Telephone Support
Volunteer). The Adolescent Telephone Support Documentation Form
contains 22 items that are asked of an adolescent during a telephone
support contact by a volunteer. The form is used to record yes/no and
open-ended responses to questions asking about substance use and
recovery-related activities.
Telephone Support Discharge Form (Telephone Support Volunteer). The
Telephone Support Discharge Form contains 10 fields to record the
following information at the end of an adolescent's participation in
telephone support: Adolescent name, today's date, volunteer name,
notification date, telephone support intake date, telephone support
discharge date, reason for discharge, number of completed sessions,
referral for more intervention, and successful contact for more
intervention.
Volunteer/Staff Survey (Telephone Support Volunteer)--See
Volunteer/Staff Survey (Project Coordinator) above.
Social Networking Moderator Log (Social Network Site Moderator).
The Social Networking Moderator Log contains 11 fields for the
moderator to record usage data for the project's social networking
site. The moderator tracks number of visits to the site, number of
unique visitors, messages posted, chat room attendance, and problems
with users.
Volunteer/Staff Survey (Social Network Site Moderator)--See
Volunteer/Staff Survey (Project Coordinator) above.
Family Program Progress Notes (Family Program Clinician). The
Family Program Progress Notes form is open-ended and provides space for
all data collected during attempted and completed family program
contacts to be recorded.
Family Program Attendance Log (Family Program Clinician). The
Family
[[Page 22938]]
Program Attendance Log is used to record 6 pieces of information about
each attempted session: Session number, scheduled date, was the session
rescheduled (yes/no), was the family member a no-show (yes/no), did the
family member attend the session (yes/no), and comments.
Family Program Case Review Report (Family Program Clinician). The
Family Program Case Review Report contains multiple rows that allow a
clinician to record information that allows the clinician and
supervisor to monitor the progress of active cases. Areas asked about
include: Family program procedures delivered, date of last session, and
weeks in family program.
Family Program Discharge Form (Family Program Clinician). The
Family Program Discharge Form contains 9 fields to record the following
information at the end of participation in the family program:
Caregiver name, today's date, adolescent name, notification date,
clinician name, family program intake date, family program discharge
date, reason for discharge, and number of completed sessions.
Volunteer/Staff Survey (Family Program Clinician)--See Volunteer/
Staff Survey (Project Coordinator) above.
Adolescent Telephone Support Quality Assurance Checklist (Support
Services Supervisor). This checklist contains 43 items that ask the
supervisor to rate how well a telephone support volunteer delivered
required service components to adolescents. Volunteers are rated on a
scale of 1 through 5 in the following areas: Substance use since last
call (no use), substance use since last call (use), substance use since
last call (still using), substance use since last call (stopped using),
attendance at 12-step meetings, recovery-related activities, activities
related to global health, follow-up since last call, closing the call,
overall, general clinical skills, and overall difficulty of session.
Social Networking Quality Assurance Checklist (Support Services
Supervisor). This checklist contains 17 items that ask the supervisor
to rate how well a social networking site moderator delivered required
service components to adolescents. The moderator is rated on a scale of
1 through 5 in the following areas: Group discussions, administrative
tasks, overall, and general skills.
Family Program QA Checklist (Support Services Supervisor). This
checklist contains 72 items that ask the supervisor to rate how well a
family program clinician delivered required service components to
family members. The clinician is rated on a scale of 1 through 5 in the
following areas: Initial meeting motivational strategies, domestic
violence precautions, functional analysis of substance use, positive
communication skills, use of positive reinforcement, time out from
positive reinforcement, allowing the identified patient to experience
the natural consequences of substance use, helping concerned
significant others' enrich their own lives, maintaining the identified
patient in recovery-oriented systems of care, and general.
Volunteer/Staff Survey (Support Services Supervisor)--See
Volunteer/Staff Survey (Project Coordinator) above.
The following table is a list of the hour burden of the information
collection by form and by respondent:
----------------------------------------------------------------------------------------------------------------
Total
annualized
Instrument/form Number of Responses per Total Hours per hour burden
respondents respondent responses response per respondent
*
----------------------------------------------------------------------------------------------------------------
Adolescent Respondent
----------------------------------------------------------------------------------------------------------------
FLF-P........................... 200 1 200 .32 .32
GAIN-I 5.6.0 Full............... 200 1 200 2 2
GAIN-M90 5.6.0 Full............. 200 4 800 1 4
SAF............................. 200 5 1000 .25 1.25
----------------------------------------------------------------------------------------------------------------
Collateral (parent/guardian/concerned other) Respondent
----------------------------------------------------------------------------------------------------------------
FLF-C........................... 200 1 200 .25 .25
GCI............................. 200 1 200 .25 .25
GCM 5.3.3....................... 200 4 800 .25 1
SAF-Collateral.................. 200 5 1000 .25 1.25
SEQ............................. 200 5 1000 .16 .8
FES............................. 200 5 1000 .08 .4
Relationship Happiness Scale 200 5 1000 .08 .4
(Caregiver)....................
----------------------------------------------------------------------------------------------------------------
Project Staff
----------------------------------------------------------------------------------------------------------------
Project Coordinator:
Eligibility Checklist....... 4 50 200 .25 12.5
Follow-Up Contact Log....... 4 50 200 .16 8
Volunteer/Staff Survey...... 4 1 4 .25 .25
Telephone Support Volunteer:
Telephone Support Case 8 450 3600 .25 112.5
Review Form................
Telephone Support Call Log.. 8 25 200 .16 4
Adolescent Telephone Support 8 450 3600 .5 225
Documentation Form.........
Telephone Support Discharge 8 25 200 .16 4
Form.......................
Volunteer/Staff Survey...... 8 1 8 .25 .25
Social Network Site Moderator:
Social Networking Moderator 1 52 52 .5 26
Log........................
Volunteer/Staff Survey...... 1 1 1 .25 .25
Family Program Clinician:
Family Program Progress 4 650 2600 .16 104
Notes......................
Family Program Attendance 4 50 200 .08 4
Log........................
Family Program Case Review 4 650 2600 .25 162.5
Report.....................
[[Page 22939]]
Family Program Discharge 4 50 200 .16 8
Form.......................
Volunteer/Staff Survey...... 4 1 4 .25 .25
Support Services Supervisor:
Adolescent Telephone Support 1 12 12 1 12
QA Checklist...............
Social Networking QA 1 12 12 .5 6
Checklist..................
Family Program QA Checklist. 1 12 12 1 12
Volunteer/Staff Survey...... 18 1 18 .25 .25
-------------------------------------------------------------------------------
Column Total............ 418 2580 .............. .............. 713.67
----------------------------------------------------------------------------------------------------------------
* Total Annualized Hour Burden Per Respondent = Responses Per Respondent x Hours Per Response.
Send comments to Summer King, SAMHSA Reports Clearance Officer,
Room 7-1044, 1 Choke Cherry Road, Rockville, MD 20857 AND e-mail her a
copy at summer.king@samhsa.hhs.gov. Written comments should be received
within 60 days of this notice.
Dated: May 11, 2009.
Elaine Parry,
Director, Office of Program Services.
[FR Doc. E9-11377 Filed 5-14-09; 8:45 am]
BILLING CODE 4162-20-P
