Improving Patient Safety System Implementation for Patients with Limited English Proficiency

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form Form #11 Semi-Structured Site Visit Interview Guide	Form and Instruction	New	Available
Form Form #10 Semi-Structured Follow-Up Interview Guide	Form and Instruction	New	Available
Form Form #9 Patient Outcome Survey - Spanish	Form and Instruction	New	Available
Form Form #9 Patient Outcome Survey	Form and Instruction	New	Available
Form Form #8 Post-training Behavior Survey	Form and Instruction	New	Available
Form Form #7 Pre-Training Behavior Survey	Form and Instruction	New	Available
Form Form #6 Learning Outcomes Survey	Form and Instruction	New	Available
Form Form #5 Training Participant Satisfaction Survey	Form and Instruction	New	Available
Form Form #4 Staff training Guide	Form and Instruction	New	Available
Form Form #3 Master-Training Guide	Form and Instruction	New	Available
Form Form #2 Pre-Work for Master-Training	Form and Instruction	New	Available
Form Form #1 Readiness Assessment Survey	Form and Instruction	New	Available
Supporting Statement Part B -- Improving Patient Safety System Implementation for Patients with LEP 5 10 11.docx	Supporting Statement B	Uploaded 2011-05-11	Available
Attachment M -- Federal Register Notice.pdf	Supplementary Document	Uploaded 2011-03-09	Available
Attachment A -- Healthcare Research and Quality Act of 1999.pdf	Supplementary Document	Uploaded 2011-03-09	Available
Supporting Statement Part A -- Improving Patient Safety System Implementation for Patients with LEP 5-6-11.doc	Supporting Statement A	Uploaded 2011-05-11	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
197080	Semi-Structured Site visit interview	Form and Instruction	New	Semi-Structured Site Visit Interview Guide
197079	Semi-Structured Follow-up interview	Form and Instruction	New	Semi-Structured Follow-Up Interview Guide
197078	Patient Outcome Survey	Form and Instruction	New	Patient Outcome Survey - Spanish
197078	Patient Outcome Survey	Form and Instruction	New	Patient Outcome Survey
197077	Post-training Behavior Survey	Form and Instruction	New	Post-training Behavior Survey
197076	Pre-Training Behavior Survey	Form and Instruction	New	Pre-Training Behavior Survey
197075	Learning Outcomes Survey	Form and Instruction	New	Learning Outcomes Survey
197074	Training Participant Satisfaction Survey	Form and Instruction	New	Training Participant Satisfaction Survey
197073	Staff Training	Form and Instruction	New	Staff training Guide
197072	Master Trainer Training	Form and Instruction	New	Master-Training Guide
197071	Pre-Work for Master-Training	Form and Instruction	New	Pre-Work for Master-Training
197070	Readiness Assessment Survey	Form and Instruction	New	Readiness Assessment Survey

ICR Details

OMB Control No: 0935-0178	ICR Reference No: 201103-0935-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/AHRQ	Agency Tracking No:
Title: Improving Patient Safety System Implementation for Patients with Limited English Proficiency
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 with change	Conclusion Date: 05/27/2011
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/26/2011
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2012	12 Months From Approved
Responses	762	0	0
Time Burden (Hours)	295	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: According to the 2009 American Community Survey (U.S. Census Bureau), approximately 57 million people - 20% of the U.S. population - speak a language other than English at home. Of that number, approximately 24 million (8.6% of the U.S. population) are defined as having Limited English Proficiency (LEP), meaning that they report speaking English less than "very well". Recent research suggests that adverse events affect LEP patients more severely than they affect English-speaking patients. In addition to linguistic barriers, LEP patients often face cultural barriers to care and low health literacy as well.

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Authorizing Statute(s): US Code: 42 USC 299 Name of Law: Healthcare Research and Quality Act of 1999
  

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:
	75 FR 76736	12/09/2010
30-day Notice:	Federal Register Citation:	Citation Date:
	76 FR 10902	02/28/2011
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 11

table that charts list of burden

IC Title	Form No.	Form Name
Learning Outcomes Survey	Form #6	Learning Outcomes Survey
Master Trainer Training	Form #3	Master-Training Guide
Patient Outcome Survey	Form #9, Form #9	Patient Outcome Survey ,   Patient Outcome Survey - Spanish
Post-training Behavior Survey	Form #8	Post-training Behavior Survey
Pre-Training Behavior Survey	Form #7, Form #7	Pre-Training Behavior Survey
Pre-Work for Master-Training	Form #2	Pre-Work for Master-Training
Readiness Assessment Survey	Form #1	Readiness Assessment Survey
Semi-Structured Follow-up interview	Form #10	Semi-Structured Follow-Up Interview Guide
Semi-Structured Site visit interview	Form #11	Semi-Structured Site Visit Interview Guide
Staff Training	Form #4	Staff training Guide
Training Participant Satisfaction Survey	Form #5	Training Participant Satisfaction Survey

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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	762	0	0	762	0	0
Annual Time Burden (Hours)	295	0	0	295	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 request.

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Annual Cost to Federal Government: $499,978

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

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

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

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Common Form ICR:  No

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

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

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

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

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

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

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

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

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

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

(v) Nature and extent of confidentiality; and

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

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

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

(j) It makes appropriate use of information technology.

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

Certification Date: 03/26/2011

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