Palliative Care: Conversations Matter Evaluation (NINR)

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 1 Nurses	Form and Instruction	New	Available
Form 1 Physicians	Form and Instruction	New	Available
supporting statement_b EVAL 8 12 13.doc	Supporting Statement B	Uploaded 2013-08-29	Available
Attachment 7_EVAL Informed Consent.doc	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 6_Privacy Officer Memo.pdf	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 5_OHSRP Documentation.doc	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 4_Tear-off Pad.pdf	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 3_Pre and Post Survey Correspondence.doc	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 1_Pre and Post Surveys_Word Version.doc	Supplementary Document	Uploaded 2013-08-29	Available
Attachment 1_Pre and Post Surveys_Word Version.doc	Supplementary Document	Uploaded 2013-08-29	Available
supporting statement_a EVAL 8 22 13.docx	Supporting Statement A	Uploaded 2013-08-29	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
208566	Nurses	Form and Instruction	New
208565	Physicians	Form and Instruction	New

ICR Details

OMB Control No: 0925-0683	ICR Reference No: 201309-0925-001
Status: Historical Active	Previous ICR Reference No:
Agency/Subagency: HHS/NIH	Agency Tracking No: 20361
Title: Palliative Care: Conversations Matter Evaluation (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: 10/30/2013
	Date Received in OIRA: 09/10/2013
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	10/31/2016	36 Months From Approved
Responses	600	0	0
Time Burden (Hours)	200	0	0
Cost Burden (Dollars)	0	0	0

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Abstract: This is the next step in NINR's Palliative Care: Conversation Matters campaign. NINR previously submitted an OMB clearance request for the pilot phase of this campaign. The campaign is now being officially launched to a wider audience and this submission is for the campaign evaluation. Palliative Care: Conversations Matter addresses 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 illnesses or life-limiting conditions. The campaign surveys are 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 campaign are effective, relevant, and useful to health care providers. Information obtained through this assessment is needed by NINR to evaluate the campaign and to obtain guidance for future campaign efforts. Respondents to this survey will be health care providers at up to ten hospitals who work with children living with serious illnesses or life-limiting conditions.

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Authorizing Statute(s): US Code: 42 USC 285q Name of Law: National Institute of Nursing Research
  

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:
	78 FR 35942	06/14/2013
30-day Notice:	Federal Register Citation:	Citation Date:
	78 FR 53152	08/28/2013
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
Nurses	1	PRE AND POST SURVEYS
Physicians	1	PRE AND POST SURVEYS

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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	600	0	0	600	0	0
Annual Time Burden (Hours)	200	0	0	200	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 ICR.

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Annual Cost to Federal Government: $27,633

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: 09/10/2013

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