Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Forms and Documents

Document Name	Status
Nurse Survey Form	Modified
Incident Information Form	Modified
Interview - Committee Chair Form	Modified
Evaluation Form - Administrators Form	Modified
10 7 2011 attachment-C4.docx Supplementary Document	2012-05-29
Justification for Change.pdf Justification for No Material/Nonsubstantive Change	2012-05-29
Appendix F updated 9.30.11.docx Supplementary Document	2011-10-13
Appendix D updated 9.30.11.docx Supplementary Document	2011-10-13

IC Document Collections

IC ID	Document Title	Status
199796	Nurse Survey Form	Modified
199795	Incident Information Form	Modified
199794	Interview - Committee Chair Form	Modified
199793	Evaluation Form - Administrators Form	Modified

ICR Details

OMB Control No: 0920-0914	ICR Reference No: 201206-0920-001
Status: Historical Active	Previous ICR Reference No: 201110-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Workplace Violence Prevention Programs In New Jersey Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved without change	Conclusion Date: 06/05/2012
	Date Received in OIRA: 06/04/2012
Terms of Clearance:

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	01/31/2015	01/31/2015	01/31/2015
Responses	4,150	0	2,150
Time Burden (Hours)	1,483	0	817
Cost Burden (Dollars)	0	0	0

---

Abstract: CDC's National Institute for Occupational Safety and Health (NIOSH) seeks clearance to conduct research on the prevention of workplace violence in the healthcare industry. The objective of this project is to evaluate the impact of the New Jersey Violence Prevention in Health Care Facilities Act.

---

Authorizing Statute(s): PL: Pub.L. 91 - 596 20.a.1 Name of Law: Occupational Safety and Health Act
  

Citations for New Statutory Requirements: None

---

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

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 4

IC Title	Form No.	Form Name
Evaluation Form - Administrators	none	Evaluation Form
Interview - Committee Chair	none	Interview
Incident Information	none	Incident Information
Nurse Survey	none	Nurse Survey

---

ICR Summary 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	4,150	2,150	0	2,000	0	0
Annual Time Burden (Hours)	1,483	817	0	666	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: There is an increase in the number of responses and the burden hours as a result of an increase in the sample size.

---

Annual Cost to Federal Government: $831,088

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

---

Common Form ICR:  No

---

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: 06/04/2012

---