Agency Information Collection Activities: Submission for OMB Review; Comment Request, 38202-38207 [E9-18315]
Download as PDF
<![CDATA[
38202
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
9 With the exception of the MSSC–R, respondents only complete Service Experience Study measures at follow-up points. See Footnote #3 for
the explanation about the average number of responses per respondent.
10 Approximate number of children/families in each sector, for the Sector and Comparison Study. This includes cases within the communities,
as well as within the comparison sample.
11 For each community, 1 respondent will be a caregiver and 3 respondents will be administrators/providers.
12 Assumes that each community will use flexible funds expenditures on average for approximately one quarter of the children/youth enrolled.
13 Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund benefits.
14 Assumes that each child/youth in system of care communities and in the comparison sample will have 100 service episodes, on average.
Written comments and
recommendations concerning the
proposed information collection should
be sent by August 28, 2009 to: SAMHSA
Desk Officer, Human Resources and
Housing Branch, Office of Management
and Budget, New Executive Office
Building, Room 10235, Washington, DC
20503; due to potential delays in OMB’s
receipt and processing of mail sent
through the U.S. Postal Service,
respondents are encouraged to submit
comments by fax to: 202–395–6974.
Dated: July 27, 2009.
Elaine Parry,
Director, Office of Program Services.
[FR Doc. E9–18317 Filed 7–30–09; 8:45 am]
BILLING CODE 4162–20–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Substance Abuse and Mental Health
Services Administration
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
Periodically, the Substance Abuse and
Mental Health Services Administration
(SAMHSA) will publish a summary of
information collection requests under
OMB review, in compliance with the
Paperwork Reduction Act (44 U.S.C.
Chapter 35). To request a copy of these
documents, call the SAMHSA Reports
Clearance Officer on (240) 276–1243.
Project: National Evaluation of the
Comprehensive Community Mental
Health Services for Children and Their
Families Program: Phase V (OMB No.
0930–0280)—Revision
The Substance Abuse and Mental
Health Services Administration
(SAMHSA) Center for Mental Health
Services (CMHS) is responsible for the
National Evaluation of the
Comprehensive Community Mental
Health Services for Children and Their
Families Program, which collects data
on child mental health outcomes, family
life, and service system development
and performance. Data will be collected
on 30 service systems and roughly 8,810
children and families.
The data collection for this evaluation
will be conducted for a 3-year period.
The core of service system data will be
collected twice (every 18 to 24 months)
during the 3-year evaluation period. A
sustainability survey will be conducted
in selected years. Service delivery and
system variables of interest include the
following: Maturity of system of care
development; adherence to the system
of care program model; services
received by youth and their families,
and the costs of those services; and
consumer service experience.
The length of time that individual
families will participate in the study
ranges from 18 to 36 months depending
on when they enter the evaluation.
Child and family outcomes of interest
will be collected at intake and during
subsequent follow-up interviews at sixmonth intervals. Client service
experience information is collected at
these follow-up interviews. Measures
included in an outcome interview are
determined by the type of assessment
(intake or follow-up), child’s age, and
whether the respondent is the caregiver
or a youth.
The outcome measures include the
following: Child symptomatology and
functioning, family functioning,
material resources, and caregiver strain.
The caregiver interview package
includes the Caregiver Information
Questionnaire, Child Behavior
Checklist, Behavioral and Emotional
Rating Scale (BERS), Education
Questionnaire, Columbia Impairment
Questionnaire, Living Situations
Questionnaire, Family Life
Questionnaire, and Caregiver Strain
Questionnaire at intake, and also
includes the Multi-service Sector
Contacts Form, Cultural Competence
and Service Provision Questionnaire
and the Youth Services Survey (a
national outcome measurement tool) at
follow-up assessments. Caregivers of
children under age 6 complete the
Vineland Screener to assess
development, and do not complete the
BERS. The Youth Interview package
includes the Youth Information
Questionnaire, Revised Children’s
Manifest Anxiety Scale, Reynolds
Depression Scale, BERS (youth version),
Delinquency Survey, Substance Use
Survey, GAIN-Quick: Substance
Dependence Scale, and Youth Services
Survey (youth version).
The evaluation also includes three
special studies: (1) An evidence-based
practices study that examines the effects
of various factors on the implementation
and use of evidence-based treatments
and approaches in system of care
communities; (2) A cultural and
linguistic competence study that
examines the extent to which the
cultural and linguistic characteristics of
communities influence program
implementation and provider
adaptation of evidence-based
treatments, and provider service
delivery decisions based on provider
culture and language; and (3) an
evaluation of the communities’ use of
reports produced by the national
evaluation for continuous quality
improvement. The national evaluation
measures address the national outcome
measures for mental health programs as
currently established by SAMHSA.
Table 1 summarizes which national
evaluation components are unchanged
from the original 2006 submission and
which are new or changed.
PWALKER on DSK8KYBLC1PROD with NOTICES
TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION
New or changed
for 2009
resubmission
No change
Nature of change
System of Care Assessment
Site Visit Tables ........................................................
Interview Protocols ...................................................
Inter-Agency Collaboration Scale (IACS) .................
VerDate Nov<24>2008
16:38 Jul 30, 2009
Jkt 217001
PO 00000
............................
............................
............................
Frm 00038
Fmt 4703
X
X
X
Sfmt 4703
E:\FR\FM\31JYN1.SGM
31JYN1
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
38203
TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION—Continued
New or changed
for 2009
resubmission
No change
Nature of change
Longitudinal Child and Family Outcome Study
Caregiver Information Questionnaire (CIQ–I) ...........
X
............................
Caregiver Information Questionnaire (CIQ–F) .........
X
............................
Caregiver Strain Questionnaire (CGSQ) ..................
Child Behavior Checklist (CBCL)/Child Behavior
Checklist 11⁄2–5 (CBCL 11⁄2–5).
Education Questionnaire—Revised (EQ–R) ............
............................
............................
X
X
X
............................
Living Situations Questionnaire (LSQ) .....................
Family Life Questionnaire (FLQ) ..............................
Behavioral and Emotional Rating Scale—Second
Edition—Parent Rating Scale (BERS–2C).
Columbia Impairment Scale (CIS) ............................
Vineland Screener (VS) ............................................
Delinquency Survey—Revised (DS–R) ....................
Behavioral and Emotional Rating Scale—Second
Edition, Youth Rating Scale (BERS–2Y).
GAIN-Quick Substance Related Issues (GAIN
Quick-R).
Substance Use Survey—Revised (SUS–R) .............
Revised Children’s Manifest Anxiety Scales
(RCMAS).
Reynolds Adolescent Depression Scale—Second
Edition (RADS–2).
Youth Information Questionnaire (YIQ–I) .................
Youth Information Questionnaire (YIQ–F) ................
............................
............................
............................
X
X
X
............................
............................
............................
............................
X
X
X
X
............................
X
............................
............................
X
X
............................
X
............................
............................
Question
Question
Question
Question
39a
39d
39a
39d
skip pattern revised.
list of medications updated.
skip pattern revised.
list of medications updated.
X
X
Slight wording change to interviewer note and the
term ‘‘day care’’ changed to ‘‘childcare.’’
Service Experience Study
Multi-Sector Service Contacts Questionnaire—Revised (MSSC–R).
Evidence-Based Practices Experience Measure
(EBPEM).
Cultural Competence and Service Provision Questionnaire (CCSP).
Youth Services Survey for Families (YSS–F) ..........
Youth Services Survey (YSS) ..................................
X
............................
............................
X
............................
X
............................
............................
Slight modification to Card 4, and Cards 6 and 7
are new.
X
X
Services and Costs Study
Flex Funds Data Dictionary ......................................
Services and Costs Data Dictionary .........................
X
X
............................
............................
New.
New.
Sustainability Study
Sustainability Survey ................................................
............................
X
Continuous Quality Improvement (CQI) Initiative Evaluation
CQI Initiative Survey .................................................
CQI Initiative Interview Guide ...................................
X
X
............................
............................
New.
New.
PWALKER on DSK8KYBLC1PROD with NOTICES
Evidence-Based Practices Study
System-level Implementation Factors Discussion
Guide.
Service-level Implementation Factors Discussion
Guide.
Consumer-level Implementation Factors Discussion
Guide.
X
............................
New.
X
............................
New.
X
............................
New.
Cultural and Linguistic Competence Study
CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Staff and Partners.
CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Caregivers.
VerDate Nov<24>2008
16:38 Jul 30, 2009
Jkt 217001
PO 00000
X
New.
X
Frm 00039
............................
............................
New.
Fmt 4703
Sfmt 4703
E:\FR\FM\31JYN1.SGM
31JYN1
38204
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
TABLE 1—STUDY COMPONENT AND INSTRUMENT REVISIONS FOR PHASE V RE-SUBMISSION—Continued
New or changed
for 2009
resubmission
No change
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
............................
New.
X
X
X
X
............................
............................
............................
............................
New.
New.
New.
New.
CCIOSAS—Beneficiaries of Self-Assessment Findings Focus Group Guide—Youth.
CCIOSAS—Participants in Self-Assessments Focus
Group Guide—Staff and Partners.
CCIOSAS—Participants in Self-Assessments Focus
Group Guide—Caregivers.
CCIOSAS—Participants in Self-Assessments Focus
Group Guide—Youth.
CCIOSAS—Users of Self-Assessment Findings
Focus Group Guide—Staff and Partners.
CCIOSAS—Users of Self-Assessment Findings
Focus Group Guide—Caregivers.
CCIOSAS—Users of Self-Assessment Findings
Focus Group Guide—Youth.
CCIOSAS—Telephone Interview—Staff and Partners.
CCEBPS—Managers of EBP Process Focus Group
Guide.
CCEBPS—Providers of EBP Focus Group Guide ...
CCEBPS—Family Focus Group Guide ....................
CCEBPS—Youth Focus Group Guide .....................
CCEBPS—Telephone Interview ...............................
Internet-based technology will be
used for data entry and management,
and for collecting data using Web-based
surveys. The average annual respondent
burden, with detail provided about
burden contributed by specific
Nature of change
measures, is estimated below. The
estimate reflects the average number of
respondents in each respondent
category, the average number of
responses per respondent per year, the
average length of time it will take for
each response, and the total average
annual burden for each category of
respondent and for all categories of
respondents combined.
TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN
[Note: Total burden is annualized over a 3-year period.]
Instrument
Number of
respondents
Respondent
Total average
number of
responses per
respondent
Hours per
response
Total burden
hours
3-year average annual
burden hours
System of Care Assessment
Interview Guides and Data Collection Forms.
Interagency Collaboration Scale
(IACS).
Key site informants.
Key site informants.
1 630
1
1.00
630
210
630
1
0.13
82
27
PWALKER on DSK8KYBLC1PROD with NOTICES
Longitudinal Child and Family Outcome Study
Caregiver Information Questionnaire
(CIQ–IC).
Caregiver Information Questionnaire
Followup (CIQ–FC).
Caregiver
Strain
Questionnaire
(CGSQ).
Child Behavior Checklist (CBCL)/
Child Behavior Checklist 11⁄2–5
(CBCL 11⁄2–5).
Education Questionnaire—Revised
(EQ–R).
Living
Situations
Questionnaire
(LSQ).
The Family Life Questionnaire (FLQ)
Behavioral and Emotional Rating
Scale—Second Edition, Parent
Rating Scale (BERS–2C).
Columbia Impairment Scale (CIS) ....
The Vineland Screener (VS) ............
VerDate Nov<24>2008
16:38 Jul 30, 2009
Caregiver ............
2 8,810
1
0.283
2,493
831
Caregiver ............
8,810
32
0.200
3,524
1,175
Caregiver ............
8,810
3
0.167
4,414
1,471
Caregiver ............
8,810
3
0.333
8,801
2,934
Caregiver ............
8,810
3
0.333
8,801
2,934
Caregiver ............
8,810
3
0.083
2,194
731
Caregiver ............
Caregiver ............
8,810
4 7,488
3
3
0.050
0.167
1,322
4,193
441
1,398
3
3
0.083
0.250
2,084
330
695
110
Caregiver ............
Caregiver ............
Jkt 217001
PO 00000
Frm 00040
5 8,369
6 1,321
Fmt 4703
Sfmt 4703
E:\FR\FM\31JYN1.SGM
31JYN1
38205
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN—Continued
[Note: Total burden is annualized over a 3-year period.]
Number of
respondents
Total average
number of
responses per
respondent
Hours per
response
Total burden
hours
3-year average annual
burden hours
Instrument
Respondent
Delinquency Survey—Revised (DS–
R).
Behavioral and Emotional Rating
Scale—Second Edition, Youth
Rating Scale (BERS–2Y).
Gain-Quick
Substance
Related
Issues (Gain Quick-R).
Substance Use Survey—Revised
(SUS–R).
Revised Children’s Manifest Anxiety
Scales (RCMAS).
Reynolds Adolescent Depression
Scale—Second Edition (RADS–2).
Youth information Questionnaire—
Baseline (YIQ–I).
Youth information Questionnaire—
Follow-up (YIQ–F).
Youth ...................
7 5,286
3
0.167
2,648
883
Youth ...................
5,286
3
0.167
2,648
883
Youth ...................
5,286
3
0.083
1,316
439
Youth ...................
5,286
3
0.100
1,586
529
Youth ...................
5,286
3
0.050
793
264
Youth ...................
5,286
3
0.050
793
264
Youth ...................
5,286
1
0.167
883
294
Youth ...................
5,286
2
0.167
1,766
589
Service Experience Study
Multi-Sector Service Contacts—Revised (MSSC–R).
Evidence-Based Practice Measure
(EBPEM).
Cultural Competence and Service
Provision Questionnaire (CCSP).
Youth
Services
Survey—Family
(YSS–F).
Youth Services Survey (YSS) ..........
Caregiver ............
8,810
82
0.250
4,405
1,468
Caregiver ............
8,810
2
0.167
2,943
981
Caregiver ............
8,810
2
0.167
2,943
981
Caregiver ............
8,810
2
0.117
2,062
687
Youth ...................
5,286
2
0.083
877
292
9 2,670
10 3
0.033
218
73
11 10,680
12 100
0.033
29,073
9,691
0.75
0.75
78
234
26
78
Services and Costs Study
Flex Funds Data Dictionary ..............
Services and Costs Data Dictionary
Local staff compiling/entering
data.
Local staff compiling/entering
data.
Sustainability Study
Sustainability Survey—Caregiver .....
Sustainability Survey—Provider .......
13 Caregiver
.........
13 Provider/Admin-
52
156
2
2
istrator.
CQI Benchmarking Initiative Evaluation
CQI Initiative Survey .........................
CQI Initiative Interview Guide ...........
Key community
staff.
Key community
staff.
150
1
0.5
75
25
50
1
1.0
50
17
PWALKER on DSK8KYBLC1PROD with NOTICES
Evidence-Based Practices Study
The Implementation Factors Discussion Guide.
The Implementation Factors Discussion Guide.
The Implementation Factors Discussion Guide.
SOC leadership
team member.
Provider ...............
90
1
0.75
68
23
60
1
0.75
45
15
Caregivers ...........
30
1
0.5
15
5
Cultural and Linguistic Competence Study
CCIOSAS—Beneficiaries of Self-Assessment Findings.
CCIOSAS—Beneficiaries of Self-Assessment Findings.
VerDate Nov<24>2008
16:38 Jul 30, 2009
Provider ...............
40
1
1.0
40
13
Administrators/
Managers.
20
1
1.5
30
10
Jkt 217001
PO 00000
Frm 00041
Fmt 4703
Sfmt 4703
E:\FR\FM\31JYN1.SGM
31JYN1
38206
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
TABLE 2—DETAILED ESTIMATE OF RESPONDENT BURDEN—Continued
[Note: Total burden is annualized over a 3-year period.]
Total average
number of
responses per
respondent
Number of
respondents
Hours per
response
Total burden
hours
3-year average annual
burden hours
Instrument
Respondent
CCIOSAS—Beneficiaries of Self-Assessment Findings.
CCIOSAS—Beneficiaries of Self-Assessment Findings.
CCIOSAS—Participants in Self-Assessments.
CCIOSAS—Participants in Self-Assessments.
CCIOSAS—Participants in Self-Assessments.
CCIOSAS—Participants in Self-Assessments.
CCIOSAS—Users of Self-Assessment Findings.
CCIOSAS—Users of Self-Assessment Findings.
CCIOSAS—Users of Self-Assessment Findings.
CCIOSAS—Users of Self-Assessment Findings.
CCIOSAS—Telephone Interview .....
CCIOSAS—Telephone Interview .....
Caregivers ...........
40
1
0.75
30
10
Youth ...................
40
1
0.75
30
10
Provider ...............
40
1
1.0
40
13
Administrators/
Managers.
Caregivers ...........
20
1
1.5
30
10
16
1
0.75
12
4
Youth ...................
16
1
0.75
12
4
Provider ...............
40
1
1.0
40
13
Administrators/
Managers.
Caregivers ...........
20
1
1.5
30
10
16
1
0.75
12
4
Youth ...................
16
1
0.75
12
4
Providers .............
Administrators/
Managers.
Providers .............
2
3
1
1
1.0
1.0
2
3
0.67
1
16
1
1.0
16
5
20
1
1.5
30
10
40
40
40
2
3
1
1
1
1
1
1.0
0.75
0.75
1.0
1.0
40
30
30
2
3
13
10
10
0.67
1
CCEBPS—Managers of EBP Process.
CCEBPS—Managers of EBP Process.
CCEBPS—Providers of EBP ............
CCEBPS—Families and Youth ........
CCEBPS—Families and Youth ........
CCEBPS—Telephone Interview .......
CCEBPS—Telephone Interview .......
Administrators/
Managers.
Providers .............
Caregivers ...........
Youth ...................
Providers .............
Administrators/
Managers.
TABLE 2—ESTIMATE OF RESPONDENT BURDEN (CONTINUED)
Number of
distinct respondents
Number of
responses per
year per
respondent
Average annual burden
per response
(hours)
Total annual
burden
(hours)
Summary of Annualized Burden Estimates for 3 Years
8,810
5,286
870
2.46
2.56
72.22
2.36
0.99
0.86
51,147
13,397
54,035
Total Summary .........................................................................................
14,996
6.54
........................
118,579
Total Annual Average Summary .......................................................
PWALKER on DSK8KYBLC1PROD with NOTICES
Caregivers ........................................................................................................
Youth ................................................................................................................
Community staff ...............................................................................................
4,989
2.18
........................
39,526
1 An average of 21 constituents in up to 30 grant communities will complete the System of Care Assessment interview. These constituents will
include site administrative staff, providers, agency representatives, family representatives, and youth.
2 Number of respondents across 30 grantees. Average based on a 5 percent attrition rate at each data collection point.
3 Average number of responses per respondent is a weighted average of the possible numbers of responses per respondent for communities
beginning data collection in FY2007 and FY2008. The maximum numbers of responses per respondent are for 24 communities beginning data
collection in FY2007, 1 follow-up data collection point remaining for children/youth recruited in year 2 (of grant community funding), 3 for children/
youth recruited in year 3, 4 for children/youth recruited in year 4, and 4 for children/youth recruited in year 5. The maximum numbers of responses per respondent are, for 6 communities beginning data collection in FY2008, 3 follow-up data collection points remaining for children/
youth recruited in year 2 (of grant community funding), 5 for children/youth recruited in year 3, 6 for children/youth recruited in year 4, and 4 for
children/youth recruited in year 5.
4 Approximate number of caregivers with children over age 5, based on Phase V data submitted as of 12/08.
5 Approximate number of caregivers with children 3 and older, based on Phase V data submitted as of 12/08.
6 Approximate number of caregivers with children 5 or under, based on Phase V data submitted as of 12/08.
7 Based on Phase III and IV finding that approximately 60 percent of the children/youth in the evaluation were 11 years old or older.
8 Respondents only complete Service Experience Study measures at follow-up points. See Footnote #3 for the explanation about the average
number of responses per respondent.
VerDate Nov<24>2008
16:38 Jul 30, 2009
Jkt 217001
PO 00000
Frm 00042
Fmt 4703
Sfmt 4703
E:\FR\FM\31JYN1.SGM
31JYN1
Federal Register / Vol. 74, No. 146 / Friday, July 31, 2009 / Notices
38207
9 Staff will enter data on flexible funds expenditures into a Web-based application or will recode existing data on flexible funds expenditures to
match the Flex Funds Data Dictionary format. Each community will use flexible funds expenditures on average for approximately one-quarter of
the estimated 356 children/youth enrolled, suggesting a total of 89 children/youth will receive services from flexible funds per community. Thus,
there will be data entered for 89 × 30 = 2,670 children/youth using the Flex Funds Data Dictionary.
10 Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund benefits.
11 Staff will collect paper-based forms from agencies and enter them into a Web-based application or will extract data from agencies’ existing
data systems. Staff will recode data to match the Services and Costs Data Dictionary format. Service and costs records will be compiled for all
356 × 30 = 10,680 children/youth enrolled.
12 Assumes that each child/youth will have 100 service episodes, on average, during his/her time in a system of care.
13 This survey will be administered in 5 communities funded in 2006, 25 communities funded in 2005, 2 communities funded in 2000, and 20
communities funded in 1999. For each community, one respondent will be a caregiver and three respondents will be administrators/providers.
Written comments and
recommendations concerning the
proposed information collection should
be sent by August 31, 2009 to: SAMHSA
Desk Officer, Human Resources and
Housing Branch, Office of Management
and Budget, New Executive Office
Building, Room 10235, Washington, DC
20503; due to potential delays in OMB’s
receipt and processing of mail sent
through the U.S. Postal Service,
respondents are encouraged to submit
comments by fax to: 202–395–6974.
Dated: July 27, 2009.
Elaine Parry,
Director, Office of Program Services.
[FR Doc. E9–18315 Filed 7–30–09; 8:45 am]
BILLING CODE 4162–20–P
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
Centers for Medicare & Medicaid
Services
[Document Identifier: CMS–43, CMS–1763,
CMS–R–194 and CMS–R–296]
PWALKER on DSK8KYBLC1PROD with NOTICES
Agency Information Collection
Activities: Submission for OMB
Review; Comment Request
AGENCY: Centers for Medicare &
Medicaid Services, HHS.
In compliance with the requirement
of section 3506(c)(2)(A) of the
Paperwork Reduction Act of 1995, the
Centers for Medicare & Medicaid
Services (CMS), Department of Health
and Human Services, is publishing the
following summary of proposed
collections for public comment.
Interested persons are invited to send
comments regarding this burden
estimate or any other aspect of this
collection of information, including any
of the following subjects: (1) The
necessity and utility of the proposed
information collection for the proper
performance of the Agency’s function;
(2) the accuracy of the estimated
burden; (3) ways to enhance the quality,
utility, and clarity of the information to
be collected; and (4) the use of
automated collection techniques or
other forms of information technology to
minimize the information collection
burden.
VerDate Nov<24>2008
16:38 Jul 30, 2009
Jkt 217001
1. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Application for
Hospital Insurance Benefits for
Individuals with End Stage Renal
Disease: Use: Effective July 1, 1973,
individuals with End Stage Renal
Disease (ESRD) became entitled to
Medicare. Because this entitlement has
a different set of requirements, the
existing applications for Medicare were
not sufficient to capture the information
needed to determine Medicare
entitlement under the ESRD provisions
of the law. The Application for Hospital
Insurance Benefits for Individuals with
End Stage Renal Disease, was designed
to capture all the information needed to
make a Medicare entitlement
determination; Form Numbers: CMS–43
(OMB#: 0938–0800; Frequency:
Reporting—Once; Affected Public:
Individuals or households; Number of
Respondents: 60,000; Total Annual
Responses: 60,000; Total Annual Hours:
25989. (For policy questions regarding
this collection contact Naomi Rappaport
at 410–786–2175. For all other issues
call 410–786–1326.)
2. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Request for
Termination of Premium Hospital and/
or Supplementary Medical Insurance:
Use: The Social Security Act (the Act)
allows a Medicare enrollee to
voluntarily terminate Supplementary
Medical Insurance (Part B) and/or the
premium Hospital Insurance (premiumPart A) coverage by filing a written
request with CMS or the Social Security
Administration (SSA). The Act also
stipulates when coverage will end based
upon the date the request was filed.
Because Medicare is recognized as a
valuable protection against the high cost
of medical and hospital bills, when an
individual wishes to voluntarily
terminate Part B and/or premium Part
A, CMS and SSA requests the reason
that an individual wishes to terminate
coverage to ensure that the individual
understands the ramifications of the
decision. The Request for Termination
of Premium Hospital and/or
Supplementary Medical Insurance,
PO 00000
Frm 00043
Fmt 4703
Sfmt 4703
provides a standardized form to satisfy
the requirements of law as well as
allowing both agencies to protect the
individual from an inappropriate
decision; Form Numbers: CMS–1763
(OMB#: 0938–0025; Frequency:
Reporting—Once; Affected Public:
Individuals or households; Number of
Respondents: 14,000; Total Annual
Responses: 14,000; Total Annual Hours:
5,831. (For policy questions regarding
this collection contact Naomi Rappaport
at 410–786–2175. For all other issues
call 410–786–1326.)
3. Type of Information Collection
Request: Extension of a currently
approved collection; Title of
Information Collection: Medicare
Disproportionate Share Adjustment
Procedures and Criteria and Supporting
Regulations in 42 CFR 412.106: Use:
Section 1886(d)(5)(F) of the Social
Security Act established the Medicare
disproportionate share adjustment
(DSH) for hospitals, which provides
additional payment to hospitals that
serve a disproportionate share of the
indigent patient population. This
payment is an add-on to the set amount
per case CMS pays to hospitals under
the Medicare Inpatient Prospective
Payment System (IPPS).
Under current regulations at 42 CFR
412.106, in order to meet the qualifying
criteria for this additional DSH
payment, a hospital must prove that a
disproportionate percentage of its
patients are low income using
Supplemental Security Income (SSI)
and Medicaid as proxies for this
determination. This percentage includes
two computations: (1) The ‘‘Medicare
fraction’’ or the ‘‘SSI ratio’’ which is the
percent of patient days for beneficiaries
who are eligible for Medicare Part A and
SSI and (2) the ‘‘Medicaid fraction’’
which is the percent of patient days for
patients who are eligible for Medicaid
but not Medicare. Once a hospital
qualifies for this DSH payment, CMS
also determines a hospital’s payment
adjustment; Form Numbers: CMS–R–
194 (OMB#: 0938–0691; Frequency:
Reporting—Occasionally; Affected
Public: Business or other for-profit and
Not-for-profit institutions; Number of
Respondents: 800; Total Annual
Responses: 800; Total Annual Hours:
E:\FR\FM\31JYN1.SGM
31JYN1
]]>Agencies
[Federal Register Volume 74, Number 146 (Friday, July 31, 2009)]
[Notices]
[Pages 38202-38207]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: E9-18315]
-----------------------------------------------------------------------
DEPARTMENT OF HEALTH AND HUMAN SERVICES
Substance Abuse and Mental Health Services Administration
Agency Information Collection Activities: Submission for OMB
Review; Comment Request
Periodically, the Substance Abuse and Mental Health Services
Administration (SAMHSA) will publish a summary of information
collection requests under OMB review, in compliance with the Paperwork
Reduction Act (44 U.S.C. Chapter 35). To request a copy of these
documents, call the SAMHSA Reports Clearance Officer on (240) 276-1243.
Project: National Evaluation of the Comprehensive Community Mental
Health Services for Children and Their Families Program: Phase V (OMB
No. 0930-0280)--Revision
The Substance Abuse and Mental Health Services Administration
(SAMHSA) Center for Mental Health Services (CMHS) is responsible for
the National Evaluation of the Comprehensive Community Mental Health
Services for Children and Their Families Program, which collects data
on child mental health outcomes, family life, and service system
development and performance. Data will be collected on 30 service
systems and roughly 8,810 children and families.
The data collection for this evaluation will be conducted for a 3-
year period. The core of service system data will be collected twice
(every 18 to 24 months) during the 3-year evaluation period. A
sustainability survey will be conducted in selected years. Service
delivery and system variables of interest include the following:
Maturity of system of care development; adherence to the system of care
program model; services received by youth and their families, and the
costs of those services; and consumer service experience.
The length of time that individual families will participate in the
study ranges from 18 to 36 months depending on when they enter the
evaluation. Child and family outcomes of interest will be collected at
intake and during subsequent follow-up interviews at six-month
intervals. Client service experience information is collected at these
follow-up interviews. Measures included in an outcome interview are
determined by the type of assessment (intake or follow-up), child's
age, and whether the respondent is the caregiver or a youth.
The outcome measures include the following: Child symptomatology
and functioning, family functioning, material resources, and caregiver
strain. The caregiver interview package includes the Caregiver
Information Questionnaire, Child Behavior Checklist, Behavioral and
Emotional Rating Scale (BERS), Education Questionnaire, Columbia
Impairment Questionnaire, Living Situations Questionnaire, Family Life
Questionnaire, and Caregiver Strain Questionnaire at intake, and also
includes the Multi-service Sector Contacts Form, Cultural Competence
and Service Provision Questionnaire and the Youth Services Survey (a
national outcome measurement tool) at follow-up assessments. Caregivers
of children under age 6 complete the Vineland Screener to assess
development, and do not complete the BERS. The Youth Interview package
includes the Youth Information Questionnaire, Revised Children's
Manifest Anxiety Scale, Reynolds Depression Scale, BERS (youth
version), Delinquency Survey, Substance Use Survey, GAIN-Quick:
Substance Dependence Scale, and Youth Services Survey (youth version).
The evaluation also includes three special studies: (1) An
evidence-based practices study that examines the effects of various
factors on the implementation and use of evidence-based treatments and
approaches in system of care communities; (2) A cultural and linguistic
competence study that examines the extent to which the cultural and
linguistic characteristics of communities influence program
implementation and provider adaptation of evidence-based treatments,
and provider service delivery decisions based on provider culture and
language; and (3) an evaluation of the communities' use of reports
produced by the national evaluation for continuous quality improvement.
The national evaluation measures address the national outcome measures
for mental health programs as currently established by SAMHSA.
Table 1 summarizes which national evaluation components are
unchanged from the original 2006 submission and which are new or
changed.
Table 1--Study Component and Instrument Revisions for Phase V Re-submission
----------------------------------------------------------------------------------------------------------------
New or changed
for 2009 No change Nature of change
resubmission
----------------------------------------------------------------------------------------------------------------
System of Care Assessment
----------------------------------------------------------------------------------------------------------------
Site Visit Tables.......................... ................. X .............................
Interview Protocols........................ ................. X .............................
Inter-Agency Collaboration Scale (IACS).... ................. X .............................
----------------------------------------------------------------------------------------------------------------
[[Page 38203]]
Longitudinal Child and Family Outcome Study
----------------------------------------------------------------------------------------------------------------
Caregiver Information Questionnaire (CIQ-I) X ................. Question 39a skip pattern
revised.
Question 39d list of
medications updated.
Caregiver Information Questionnaire (CIQ-F) X ................. Question 39a skip pattern
revised.
Question 39d list of
medications updated.
Caregiver Strain Questionnaire (CGSQ)...... ................. X .............................
Child Behavior Checklist (CBCL)/Child ................. X .............................
Behavior Checklist 1\1/2\-5 (CBCL 1\1/2\-
5).
Education Questionnaire--Revised (EQ-R).... X ................. Slight wording change to
interviewer note and the
term ``day care'' changed to
``childcare.''
Living Situations Questionnaire (LSQ)...... ................. X .............................
Family Life Questionnaire (FLQ)............ ................. X .............................
Behavioral and Emotional Rating Scale-- ................. X .............................
Second Edition--Parent Rating Scale (BERS-
2C).
Columbia Impairment Scale (CIS)............ ................. X .............................
Vineland Screener (VS)..................... ................. X .............................
Delinquency Survey--Revised (DS-R)......... ................. X .............................
Behavioral and Emotional Rating Scale-- ................. X .............................
Second Edition, Youth Rating Scale (BERS-
2Y).
GAIN-Quick Substance Related Issues (GAIN ................. X .............................
Quick-R).
Substance Use Survey--Revised (SUS-R)...... ................. X .............................
Revised Children's Manifest Anxiety Scales ................. X .............................
(RCMAS).
Reynolds Adolescent Depression Scale-- ................. X .............................
Second Edition (RADS-2).
Youth Information Questionnaire (YIQ-I).... ................. X .............................
Youth Information Questionnaire (YIQ-F).... ................. X .............................
----------------------------------------------------------------------------------------------------------------
Service Experience Study
----------------------------------------------------------------------------------------------------------------
Multi-Sector Service Contacts X ................. Slight modification to Card
Questionnaire--Revised (MSSC-R). 4, and Cards 6 and 7 are
new.
Evidence-Based Practices Experience Measure ................. X .............................
(EBPEM).
Cultural Competence and Service Provision ................. X .............................
Questionnaire (CCSP).
Youth Services Survey for Families (YSS-F). ................. X .............................
Youth Services Survey (YSS)................ ................. X .............................
----------------------------------------------------------------------------------------------------------------
Services and Costs Study
----------------------------------------------------------------------------------------------------------------
Flex Funds Data Dictionary................. X ................. New.
Services and Costs Data Dictionary......... X ................. New.
----------------------------------------------------------------------------------------------------------------
Sustainability Study
----------------------------------------------------------------------------------------------------------------
Sustainability Survey...................... ................. X .............................
----------------------------------------------------------------------------------------------------------------
Continuous Quality Improvement (CQI) Initiative Evaluation
----------------------------------------------------------------------------------------------------------------
CQI Initiative Survey...................... X ................. New.
CQI Initiative Interview Guide............. X ................. New.
----------------------------------------------------------------------------------------------------------------
Evidence-Based Practices Study
----------------------------------------------------------------------------------------------------------------
System-level Implementation Factors X ................. New.
Discussion Guide.
Service-level Implementation Factors X ................. New.
Discussion Guide.
Consumer-level Implementation Factors X ................. New.
Discussion Guide.
----------------------------------------------------------------------------------------------------------------
Cultural and Linguistic Competence Study
----------------------------------------------------------------------------------------------------------------
CCIOSAS--Beneficiaries of Self-Assessment X ................. New.
Findings Focus Group Guide--Staff and
Partners.
CCIOSAS--Beneficiaries of Self-Assessment X ................. New.
Findings Focus Group Guide--Caregivers.
[[Page 38204]]
CCIOSAS--Beneficiaries of Self-Assessment X ................. New.
Findings Focus Group Guide--Youth.
CCIOSAS--Participants in Self-Assessments X ................. New.
Focus Group Guide--Staff and Partners.
CCIOSAS--Participants in Self-Assessments X ................. New.
Focus Group Guide--Caregivers.
CCIOSAS--Participants in Self-Assessments X ................. New.
Focus Group Guide--Youth.
CCIOSAS--Users of Self-Assessment Findings X ................. New.
Focus Group Guide--Staff and Partners.
CCIOSAS--Users of Self-Assessment Findings X ................. New.
Focus Group Guide--Caregivers.
CCIOSAS--Users of Self-Assessment Findings X ................. New.
Focus Group Guide--Youth.
CCIOSAS--Telephone Interview--Staff and X ................. New.
Partners.
CCEBPS--Managers of EBP Process Focus Group X ................. New.
Guide.
CCEBPS--Providers of EBP Focus Group Guide. X ................. New.
CCEBPS--Family Focus Group Guide........... X ................. New.
CCEBPS--Youth Focus Group Guide............ X ................. New.
CCEBPS--Telephone Interview................ X ................. New.
----------------------------------------------------------------------------------------------------------------
Internet-based technology will be used for data entry and
management, and for collecting data using Web-based surveys. The
average annual respondent burden, with detail provided about burden
contributed by specific measures, is estimated below. The estimate
reflects the average number of respondents in each respondent category,
the average number of responses per respondent per year, the average
length of time it will take for each response, and the total average
annual burden for each category of respondent and for all categories of
respondents combined.
Table 2--Detailed Estimate of Respondent Burden
[Note: Total burden is annualized over a 3-year period.]
--------------------------------------------------------------------------------------------------------------------------------------------------------
Total average
Number of number of Hours per Total burden 3-year average
Instrument Respondent respondents responses per response hours annual burden
respondent hours
--------------------------------------------------------------------------------------------------------------------------------------------------------
System of Care Assessment
--------------------------------------------------------------------------------------------------------------------------------------------------------
Interview Guides and Data Collection Forms Key site informants......... \1\ 630 1 1.00 630 210
Interagency Collaboration Scale (IACS).... Key site informants......... 630 1 0.13 82 27
--------------------------------------------------------------------------------------------------------------------------------------------------------
Longitudinal Child and Family Outcome Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
Caregiver Information Questionnaire (CIQ- Caregiver................... \2\ 8,810 1 0.283 2,493 831
IC).
Caregiver Information Questionnaire Caregiver................... 8,810 \3\ 2 0.200 3,524 1,175
Followup (CIQ-FC).
Caregiver Strain Questionnaire (CGSQ)..... Caregiver................... 8,810 3 0.167 4,414 1,471
Child Behavior Checklist (CBCL)/Child Caregiver................... 8,810 3 0.333 8,801 2,934
Behavior Checklist 1\1/2\-5 (CBCL 1\1/2\-
5).
Education Questionnaire--Revised (EQ-R)... Caregiver................... 8,810 3 0.333 8,801 2,934
Living Situations Questionnaire (LSQ)..... Caregiver................... 8,810 3 0.083 2,194 731
The Family Life Questionnaire (FLQ)....... Caregiver................... 8,810 3 0.050 1,322 441
Behavioral and Emotional Rating Scale-- Caregiver................... \4\ 7,488 3 0.167 4,193 1,398
Second Edition, Parent Rating Scale (BERS-
2C).
Columbia Impairment Scale (CIS)........... Caregiver................... \5\ 8,369 3 0.083 2,084 695
The Vineland Screener (VS)................ Caregiver................... \6\ 1,321 3 0.250 330 110
[[Page 38205]]
Delinquency Survey--Revised (DS-R)........ Youth....................... \7\ 5,286 3 0.167 2,648 883
Behavioral and Emotional Rating Scale-- Youth....................... 5,286 3 0.167 2,648 883
Second Edition, Youth Rating Scale (BERS-
2Y).
Gain-Quick Substance Related Issues (Gain Youth....................... 5,286 3 0.083 1,316 439
Quick-R).
Substance Use Survey--Revised (SUS-R)..... Youth....................... 5,286 3 0.100 1,586 529
Revised Children's Manifest Anxiety Scales Youth....................... 5,286 3 0.050 793 264
(RCMAS).
Reynolds Adolescent Depression Scale-- Youth....................... 5,286 3 0.050 793 264
Second Edition (RADS-2).
Youth information Questionnaire--Baseline Youth....................... 5,286 1 0.167 883 294
(YIQ-I).
Youth information Questionnaire--Follow-up Youth....................... 5,286 2 0.167 1,766 589
(YIQ-F).
--------------------------------------------------------------------------------------------------------------------------------------------------------
Service Experience Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
Multi-Sector Service Contacts--Revised Caregiver................... 8,810 \8\ 2 0.250 4,405 1,468
(MSSC-R).
Evidence-Based Practice Measure (EBPEM)... Caregiver................... 8,810 2 0.167 2,943 981
Cultural Competence and Service Provision Caregiver................... 8,810 2 0.167 2,943 981
Questionnaire (CCSP).
Youth Services Survey--Family (YSS-F)..... Caregiver................... 8,810 2 0.117 2,062 687
Youth Services Survey (YSS)............... Youth....................... 5,286 2 0.083 877 292
--------------------------------------------------------------------------------------------------------------------------------------------------------
Services and Costs Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
Flex Funds Data Dictionary................ Local staff compiling/ \9\ 2,670 \10\ 3 0.033 218 73
entering data.
Services and Costs Data Dictionary........ Local staff compiling/ \11\ 10,680 \12\ 100 0.033 29,073 9,691
entering data.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sustainability Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
Sustainability Survey--Caregiver.......... \13\ Caregiver.............. 52 2 0.75 78 26
Sustainability Survey--Provider........... \13\ Provider/Administrator. 156 2 0.75 234 78
--------------------------------------------------------------------------------------------------------------------------------------------------------
CQI Benchmarking Initiative Evaluation
--------------------------------------------------------------------------------------------------------------------------------------------------------
CQI Initiative Survey..................... Key community staff......... 150 1 0.5 75 25
CQI Initiative Interview Guide............ Key community staff......... 50 1 1.0 50 17
--------------------------------------------------------------------------------------------------------------------------------------------------------
Evidence-Based Practices Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
The Implementation Factors Discussion SOC leadership team member.. 90 1 0.75 68 23
Guide.
The Implementation Factors Discussion Provider.................... 60 1 0.75 45 15
Guide.
The Implementation Factors Discussion Caregivers.................. 30 1 0.5 15 5
Guide.
--------------------------------------------------------------------------------------------------------------------------------------------------------
Cultural and Linguistic Competence Study
--------------------------------------------------------------------------------------------------------------------------------------------------------
CCIOSAS--Beneficiaries of Self-Assessment Provider.................... 40 1 1.0 40 13
Findings.
CCIOSAS--Beneficiaries of Self-Assessment Administrators/Managers..... 20 1 1.5 30 10
Findings.
[[Page 38206]]
CCIOSAS--Beneficiaries of Self-Assessment Caregivers.................. 40 1 0.75 30 10
Findings.
CCIOSAS--Beneficiaries of Self-Assessment Youth....................... 40 1 0.75 30 10
Findings.
CCIOSAS--Participants in Self-Assessments. Provider.................... 40 1 1.0 40 13
CCIOSAS--Participants in Self-Assessments. Administrators/Managers..... 20 1 1.5 30 10
CCIOSAS--Participants in Self-Assessments. Caregivers.................. 16 1 0.75 12 4
CCIOSAS--Participants in Self-Assessments. Youth....................... 16 1 0.75 12 4
CCIOSAS--Users of Self-Assessment Findings Provider.................... 40 1 1.0 40 13
CCIOSAS--Users of Self-Assessment Findings Administrators/Managers..... 20 1 1.5 30 10
CCIOSAS--Users of Self-Assessment Findings Caregivers.................. 16 1 0.75 12 4
CCIOSAS--Users of Self-Assessment Findings Youth....................... 16 1 0.75 12 4
CCIOSAS--Telephone Interview.............. Providers................... 2 1 1.0 2 0.67
CCIOSAS--Telephone Interview.............. Administrators/Managers..... 3 1 1.0 3 1
CCEBPS--Managers of EBP Process........... Providers................... 16 1 1.0 16 5
CCEBPS--Managers of EBP Process........... Administrators/Managers..... 20 1 1.5 30 10
CCEBPS--Providers of EBP.................. Providers................... 40 1 1.0 40 13
CCEBPS--Families and Youth................ Caregivers.................. 40 1 0.75 30 10
CCEBPS--Families and Youth................ Youth....................... 40 1 0.75 30 10
CCEBPS--Telephone Interview............... Providers................... 2 1 1.0 2 0.67
CCEBPS--Telephone Interview............... Administrators/Managers..... 3 1 1.0 3 1
--------------------------------------------------------------------------------------------------------------------------------------------------------
Table 2--Estimate of Respondent Burden (Continued)
----------------------------------------------------------------------------------------------------------------
Number of Average annual
Number of responses per burden per Total annual
distinct year per response burden (hours)
respondents respondent (hours)
----------------------------------------------------------------------------------------------------------------
Summary of Annualized Burden Estimates for 3 Years
----------------------------------------------------------------------------------------------------------------
Caregivers...................................... 8,810 2.46 2.36 51,147
Youth........................................... 5,286 2.56 0.99 13,397
Community staff................................. 870 72.22 0.86 54,035
---------------------------------------------------------------
Total Summary............................... 14,996 6.54 .............. 118,579
---------------------------------------------------------------
Total Annual Average Summary............ 4,989 2.18 .............. 39,526
----------------------------------------------------------------------------------------------------------------
\1\ An average of 21 constituents in up to 30 grant communities will complete the System of Care Assessment
interview. These constituents will include site administrative staff, providers, agency representatives,
family representatives, and youth.
\2\ Number of respondents across 30 grantees. Average based on a 5 percent attrition rate at each data
collection point.
\3\ Average number of responses per respondent is a weighted average of the possible numbers of responses per
respondent for communities beginning data collection in FY2007 and FY2008. The maximum numbers of responses
per respondent are for 24 communities beginning data collection in FY2007, 1 follow-up data collection point
remaining for children/youth recruited in year 2 (of grant community funding), 3 for children/youth recruited
in year 3, 4 for children/youth recruited in year 4, and 4 for children/youth recruited in year 5. The maximum
numbers of responses per respondent are, for 6 communities beginning data collection in FY2008, 3 follow-up
data collection points remaining for children/youth recruited in year 2 (of grant community funding), 5 for
children/youth recruited in year 3, 6 for children/youth recruited in year 4, and 4 for children/youth
recruited in year 5.
\4\ Approximate number of caregivers with children over age 5, based on Phase V data submitted as of 12/08.
\5\ Approximate number of caregivers with children 3 and older, based on Phase V data submitted as of 12/08.
\6\ Approximate number of caregivers with children 5 or under, based on Phase V data submitted as of 12/08.
\7\ Based on Phase III and IV finding that approximately 60 percent of the children/youth in the evaluation were
11 years old or older.
\8\ Respondents only complete Service Experience Study measures at follow-up points. See Footnote 3 for
the explanation about the average number of responses per respondent.
[[Page 38207]]
\9\ Staff will enter data on flexible funds expenditures into a Web-based application or will recode existing
data on flexible funds expenditures to match the Flex Funds Data Dictionary format. Each community will use
flexible funds expenditures on average for approximately one-quarter of the estimated 356 children/youth
enrolled, suggesting a total of 89 children/youth will receive services from flexible funds per community.
Thus, there will be data entered for 89 x 30 = 2,670 children/youth using the Flex Funds Data Dictionary.
\10\ Assumes that three expenditures, on average, will be spent on each child/youth receiving flexible fund
benefits.
\11\ Staff will collect paper-based forms from agencies and enter them into a Web-based application or will
extract data from agencies' existing data systems. Staff will recode data to match the Services and Costs Data
Dictionary format. Service and costs records will be compiled for all 356 x 30 = 10,680 children/youth
enrolled.
\12\ Assumes that each child/youth will have 100 service episodes, on average, during his/her time in a system
of care.
\13\ This survey will be administered in 5 communities funded in 2006, 25 communities funded in 2005, 2
communities funded in 2000, and 20 communities funded in 1999. For each community, one respondent will be a
caregiver and three respondents will be administrators/providers.
Written comments and recommendations concerning the proposed
information collection should be sent by August 31, 2009 to: SAMHSA
Desk Officer, Human Resources and Housing Branch, Office of Management
and Budget, New Executive Office Building, Room 10235, Washington, DC
20503; due to potential delays in OMB's receipt and processing of mail
sent through the U.S. Postal Service, respondents are encouraged to
submit comments by fax to: 202-395-6974.
Dated: July 27, 2009.
Elaine Parry,
Director, Office of Program Services.
[FR Doc. E9-18315 Filed 7-30-09; 8:45 am]
BILLING CODE 4162-20-P
