Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Home Healthcare Aides Survey	Form	New	Available
Employee Incident	Form	New	Available
Nursing Home Administrators Survey	Form	New	Available
Nurse Survey	Form	Modified	Repair queued
Incident Information	Form	Modified	Available
Interview	Form	Modified	Available
Evaluation Form	Form	Modified	Available
Supporting Statement Part B.doc	Supporting Statement B	Uploaded 2012-11-26	Available
Appendix H 11.1.2012.docx	Supplementary Document	Uploaded 2012-11-27	Available
Appendix G.docx	Supplementary Document	Uploaded 2012-11-27	Repair queued
Appendix F3.docx	Supplementary Document	Uploaded 2012-11-27	Available
Appendix F2.docx	Supplementary Document	Uploaded 2012-11-27	Available
Appendix F1.docx	Supplementary Document	Uploaded 2012-11-27	Available
Appendix D.docx	Supplementary Document	Uploaded 2012-11-27	Available
Appendix E HSRB 11.1.12.rtf	Supplementary Document	Uploaded 2012-11-27	Available
Appendix I- public comment.docx	Supplementary Document	Uploaded 2012-11-26	Available
Appendix B 60day FRN.pdf	Supplementary Document	Uploaded 2012-11-26	Available
Appendix A.docx	Supplementary Document	Uploaded 2012-11-26	Available
Supporting Statement Part A.docx	Supporting Statement A	Uploaded 2012-11-27	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205005	Home Healthcare Aides Survey	Form	New	Home Healthcare Aides Survey
205004	Nursing Home Administrators Employee Incident Information	Form	New	Employee Incident
205003	Nursing Home Administrators Committee Chair Interview	Other-Interview	New
205002	Nursing Home Administrators Survey	Form	New	Nursing Home Administrators Survey
199796	Nurse (RN and LPN) Survey	Form	Modified	Nurse Survey
199795	Hospital Administrators Employee Incident Information	Form	Modified	Incident Information
199794	Hospital Administrators Committee Chair Interview	Form	Modified	Interview
199793	Hospital Administrators Evaluation Form	Form	Modified	Evaluation Form

ICR Details

OMB Control No: 0920-0914	ICR Reference No: 201212-0920-001
Status: Historical Active	Previous ICR Reference No: 201206-0920-003
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Workplace Violence Prevention Programs In New Jersey Healthcare Facilities
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/04/2013
Retrieve Notice of Action (NOA)	Date Received in OIRA: 12/03/2012
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	36 Months From Approved	01/31/2015
Responses	2,738	0	4,150
Time Burden (Hours)	960	0	1,483
Cost Burden (Dollars)	0	0	0

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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.

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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

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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:
	77 FR 45617	08/01/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	77 FR 70781	11/27/2012
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 8

table that charts list of burden

IC Title	Form No.	Form Name
Home Healthcare Aides Survey	none	Home Healthcare Aides Survey
Hospital Administrators Committee Chair Interview	none	Interview
Hospital Administrators Employee Incident Information	none	Incident Information
Hospital Administrators Evaluation Form	none	Evaluation Form
Nurse (RN and LPN) Survey	none	Nurse Survey
Nursing Home Administrators Committee Chair Interview
Nursing Home Administrators Employee Incident Information	none	Employee Incident
Nursing Home Administrators Survey	none	Nursing Home Administrators 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	2,738	4,150	0	1,354	-2,766	0
Annual Time Burden (Hours)	960	1,483	0	465	-988	0
Annual Cost Burden (Dollars)	0	0	0	0	0	0

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

Burden Increase Due to:

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

Burden Reduction Due to: Miscellaneous Actions

Short Statement: The currently approved burden was over-estimated (not annualized), and annualization now results in a burden decrease. This request for revision adds two new respondent groups, resulting in an increase in burden.

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Annual Cost to Federal Government: $964,367

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: 12/03/2012

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