2010-12643. 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 [phone].

Project: FASD Diagnosis and Intervention Programs in the Fetal Alcohol Spectrum Disorder (FASD) Center of Excellence—New

Since 2001, SAMHSA's Center for Substance Abuse Prevention has been operating a Fetal Alcohol Spectrum Disorder (FASD) Center of Excellence which addresses FASD mainly by providing trainings and technical assistance and developing and supporting systems of care that respond to FASD using effective evidence-based practices and interventions.

Currently the integration of evidence-based practices into service delivery organizations is being accomplished through subcontracts. One such intervention which integrates diagnosis and intervention strategies into existing service delivery organizations is the FASD Diagnosis and Intervention programs targeting children 0-18 years of age. The Diagnosis and Intervention programs use the following 11 data collection tools.

Description of Instruments/Activity for the Diagnosis and Intervention Programs

Instrument/Activity	Description
Screening and Diagnosis Tool	The purpose of the screening and diagnosis tool is to determine eligibility to participate in the SAMHSA FASD Center Diagnosis and Treatment Intervention. The form includes demographic, screening, and diagnostic data.
Positive Monitor Tracking	The Positive Monitor Tracking form is to monitor the outcome of placing a child (ages 0-3 years) on a positive monitor.
Services Child is Receiving at the time of the FASD Diagnosis	The Services Child is Receiving at the time of the FASD Diagnosis form is to record services the child is receiving at the time of an FASD diagnosis.
Services Planned and Provided based on Diagnostic Evaluation	The Services Planned and Provided based on Diagnostic Evaluation form is to record services planned and received based on the diagnostic evaluation.
Services Delivery Tracking Form	The Services Delivery Tracking form is for the services provided during every visit.
End of Intervention/Program Improvement Measure—Case Manager	The End of Intervention/Program Improvement Measure—Case Manager form is for the case manager to report on the overall improvement in the child as a result of receiving services.
End of Intervention/Program Improvement Measure—Parent/Guardian	The End of Intervention/Program Improvement Measure—Parent/Guardian form is for the parent/guardian to report on the overall improvement in the child as a result of receiving services.
End of Intervention/Program Customer Satisfaction with Service	The End of Intervention/Program Customer Satisfaction with Service form is to determine customer satisfaction (parents) with the SAMHSA FASD Center Diagnosis and Intervention project.
Outcome Measures (Children 0-7 years)	The Outcome Measures (Children 0-7 years) form is an outcomes measure checklist used to record measures every six months from start of service to end of service, at end of intervention, at 6 months follow-up, and 12 months follow-up.
Outcome Measures (Children 8-18 years)	The Outcome Measures (Children 8-18 years) form is an outcomes measure checklist used to record measures every six months from start of service to end of service, at end of intervention, at 6 months follow-up, and 12 months follow-up.
Lost to follow-up	The Lost to follow-up form is used if the child is no longer accessible for follow-up.

Eight subcontracts were awarded in February 2008 to integrate the FASD Diagnosis and Intervention program within existing service delivery organization sites. Using an integrated service delivery model all sites are screening children using an FASD screening tool, obtaining a diagnostic evaluation, and providing services/interventions as indicated by the diagnostic evaluation. Specific interventions are based upon the individual child's diagnosis. Six of the sites are integrating the FASD Diagnosis and Intervention projects either in a child mental health provider setting or in a dependency court setting and serve children ages 0-7 years. Two of the sites are delinquency courts and serve children 10-18 years of age. Data collection at all sites involves administering the screening and diagnosis tool, recording process level indicators such as type and units of service provided; improvement in functionality and outcome measures such as school performance, stability in housing/placement, and adjudication measures (10-18 yrs only). Data will be collected at baseline, monthly, every six months from start of service to end of service, at end of intervention, at 6 months follow-up, and 12 months follow-up.

Estimated Annualized Burden Hours

Instrument/Activity	Number of respondents	Number of responses per respondent	Total number of responses	Average burden per response	Total burden hours per collection
Client Surveys: Children 0-7:
Screening and Diagnosis Tool	1400	1	1400	0.17	238
Positive Monitor Tracking	450	1	450	0.03	14
Services Child is Receiving at the time of the FASD Diagnosis	750	1	750	0.17	128
Services Planned and Provided based on Diagnostic Evaluation	750	1	750	0.33	248
Services Delivery Tracking Form	750	12	9000	0.08	720
End of Intervention/Program Improvement Measure—Case Manager	750	1	750	0.02	15
End of Intervention/Program Improvement Measure—Parent/Guardian	750	1	750	0.02	15
End of Intervention/Program Customer Satisfaction with Service	750	1	750	0.03	23
Outcome Measures (Children 0-7 years)	750	5	3750	0.08	300
Lost to follow-up	135	1	135	0.03	4
Client Surveys: Children 8-18:
Screening and Diagnosis Tool	100	1	100	0.17	17
Services Child is Receiving at the time of the FASD Diagnosis	50	1	50	0.17	9
Services Planned and Provided based on Diagnostic Evaluation	50	1	50	0.33	17
Services Delivery Tracking Form	50	12	600	0.08	48
End of Intervention/Program Improvement Measure—Case Manager	50	1	50	0.02	1
End of Intervention/Program Improvement Measure—Parent/Guardian	50	1	50	0.02	1
End of Intervention/Program Customer Satisfaction with Service	50	1	50	0.03	2
Outcome Measures (Children 8-18 years)	50	5	250	0.08	20
Lost to follow-up	15	1	15	0.03	1
TOTAL	7,700	49	19,700		1,821

Written comments and recommendations concerning the proposed information collection should be sent by June 25, 2010 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: 202-395-5806.

Dated: May 17, 2010.

Elaine Parry,

Director, Office of Program Services.