Pediatric Palliative Care Campaign Pilot Survey (NINR)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Nurses (Pediatric Palliative Care Campaign Pilot Survey)	Form and Instruction	New	Available
Form 1 Physicians (Pediatric Palliative Care Campaign Pilot Survey)	Form and Instruction	New	Available
supporting statement_b PPC.doc	Supporting Statement B	Uploaded 2013-03-13	Available
Attachment 6 NINR Pediatric Palliative Care Campaign Pilot Survey 2013.doc	Supplementary Document	Uploaded 2013-03-22	Repair queued
Attachment 7_PPC Informed Consent.doc	Supplementary Document	Uploaded 2013-03-13	Available
Attachment 3_PPC Correspondence.doc	Supplementary Document	Uploaded 2013-03-13	Available
Attachment 4_Tear-off Pad.pdf	Supplementary Document	Uploaded 2013-03-13	Available
Attachment 5_OHSRP Documentation.doc	Supplementary Document	Uploaded 2013-03-13	Available
Attachment 1_Survey Word Version.doc	Supplementary Document	Uploaded 2013-03-13	Available
Attachment 1_Survey Word Version.doc	Supplementary Document	Uploaded 2013-03-13	Available
supporting statement_a PPC2.doc	Supporting Statement A	Uploaded 2013-03-13	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
206302	Nurses (Pediatric Palliative Care Campaign Pilot Survey)	Form and Instruction	New
206301	Physicians (Pediatric Palliative Care Campaign Pilot Survey)	Form and Instruction	New

ICR Details

OMB Control No: 0925-0672	ICR Reference No: 201303-0925-005
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No: 19135
Title: Pediatric Palliative Care Campaign Pilot Survey (NINR)
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: 05/13/2013
	Date Received in OIRA: 03/29/2013
Terms of Clearance: Approved with the understanding that the results from this collection cannot be generalized beyond the 2 pilot sites surveyed.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2016	36 Months From Approved
Responses	50	0	0
Time Burden (Hours)	26	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: NINR developed a Pediatric Palliative Care Campaign to address the communications challenges faced by health care providers who recommend and provide palliative care to pediatric populations. NINR is launching this effort to increase the use of palliative care for children living with serious illness or life-limiting conditions. The pilot campaign survey is designed to collect feedback from health care providers who are involved in pediatric palliative care to ensure that the information and materials being disseminated as part of the pilot are effective, relevant, and useful to health care providers and to better understand current perceptions, challenges, and information needs when it comes to discussing pediatric palliative care. Information obtained through this assessment is needed by NINR to evaluate the pilot campaign materials and to deliver strategic and actionable guidance for refining the materials so that they can be used by a wider audience of health care providers. Respondents to this survey will be health care providers at two pilot site hospitals who work with children living with serious illness or life-limiting conditions.

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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:
	77 FR 76053	12/26/2012
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 15958	03/13/2013
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 2

table that charts list of burden

IC Title	Form No.	Form Name
Physicians (Pediatric Palliative Care Campaign Pilot Survey)	1	Pediatric Palliative Care Campaign Pilot Survey
Nurses (Pediatric Palliative Care Campaign Pilot Survey)	1	Pediatric Palliative Care Campaign Pilot 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	50	0	0	50	0	0
Annual Time Burden (Hours)	26	0	0	26	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 collection of information.

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Annual Cost to Federal Government: $29,000

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]? 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: 03/29/2013

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