Pilot Study of Proposed Nursing Home Survey on Resident Safety

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
pilots memo.doc	Supplementary Document	Uploaded 2007-07-03	Available
SUPPORTING STATEMENT NH SOPS Part B 2-21-07.doc	Supporting Statement B	Uploaded 0000-00-00	Available
SUPPORTING STATEMENT NH SOPS Part A 2-21-07.doc	Supporting Statement A	Uploaded 0000-00-00	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
178948	Pilot Study of Proposed Nursing Home Survey on Resident Safety	Other-Questionnaire and instructions	New

ICR Details

OMB Control No: 0935-0132	ICR Reference No: 200703-0935-002
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Pilot Study of Proposed Nursing Home Survey on Resident Safety
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 07/05/2007
	Date Received in OIRA: 03/07/2007
Terms of Clearance: This ICR is approved consistent with the memo of 6/28/07. Absent a large scale validation study, AHRQ will use caution in making claims about the validity of results derived from this instrument.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	07/31/2010	36 Months From Approved
Responses	3,850	0	0
Time Burden (Hours)	963	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This activity is an expansion and refinement of AHRQ's Hospital Survey on Patient Safety Culture (HSOPSC)which was developed and released to the public for use in November 2004. This proposed new tool is based on the HSOPSC but also contains new and revised items as well as dimensions that more accurately apply to the nursing home setting. The instrument will be pilot tested with staff in 40 nursing homes. The data collected will be analyzed to determine the psychometric properties of the survey's items and dimensions and provide nformation for the revision and shortening of the final survey based on an assessment of its reliability and construct validity. The final survey will be made publicly available to enable nursing homes to assess their resident safety culture.

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Authorizing Statute(s): None

Citations for New Statutory Requirements: None

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Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	71 FR 74536	12/12/2006
30-day Notice:	Federal Register Citation:	Citation Date:
	72 FR 6730	02/13/2007
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 1

table that charts list of burden

IC Title	Form No.	Form Name
Pilot Study of Proposed Nursing Home Survey on Resident Safety

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,850	0	0	3,850	0	0
Annual Time Burden (Hours)	963	0	0	963	0	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new information collection.

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Annual Cost to Federal Government: $320,000

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Is the Supporting Statement intended to be a Privacy Impact Assessment required by the E-Government Act of 2002? No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? Uncollected

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? Uncollected

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? Uncollected

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 03/07/2007

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