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 Aide Survey	Form	Modified	Available
Employee Incident	Form	Modified	Available
Nursing Home Administrators Survey	Form	Modified	Available
Nurse Survey	Form	Modified	Available
Incident Information	Form	Modified	Repair queued
Interview	Form	Modified	Available
Evaluation Form	Form	Modified	Available
Revised- Appendix D.docx	Supplementary Document	Uploaded 2014-03-19	Available
Justification.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2014-03-19	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205005	Home Healthcare Aides Survey	Form	Modified	Home Healthcare Aide Survey
205004	Nursing Home Administrators Employee Incident Information	Form	Modified	Employee Incident
205003	Nursing Home Administrators Committee Chair Interview	Other-Interview	Modified
205002	Nursing Home Administrators Survey	Form	Modified	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: 201403-0920-011
Status: Historical Active	Previous ICR Reference No: 201306-0920-005
Agency/Subagency: HHS/CDC	Agency Tracking No: 21597
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: 03/20/2014
Retrieve Notice of Action (NOA)	Date Received in OIRA: 03/20/2014
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	02/29/2016	02/29/2016
Responses	2,738	0	2,738
Time Burden (Hours)	960	0	960
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. This revision request seeks approval to add the collection of data from nursing home administrators and home healthcare aides.

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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

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 Aide 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	2,738	0	0	0	0
Annual Time Burden (Hours)	960	960	0	0	0	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: No

Burden Reduction Due to:

Short Statement:

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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: 03/20/2014

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