CMS-10567.Generic_Clearance_Submission_Template

CMS-10567.Generic_Clearance_Submission_Template.doc

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

CMS-10567.Generic_Clearance_Submission_Template

OMB: 0938-1185

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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0938-NEW)

T ITLE OF INFORMATION COLLECTION:


Peer Coach Assessment


PURPOSE:

The purpose of the survey is to assess peer coaches for both their areas of expertise and modalities with which they would be willing to participate; fitting expertise, expertise, and comfort level (e.g., speak on webinar or at a conference vs. one-on-one). The intended use of the information gathered will drive communication with the peer coaches and provide a solid basis for ideal pairing in peer coaching opportunities. Information collected will be reviewed and analyzed to determine the ideal pairing between nursing homes/activities/interactive opportunities and peer coaches.


The information will be used by the QIN-QIO staff to assess opportunities for engagement that are a good fit for these volunteer experts. For example, if a peer coach states he/she is comfortable with assisting one-on-one, TMF would look for those opportunities and not request he/she as a speaker on a webinar or live conference event.



DESCRIPTION OF RESPONDENTS:

Respondents are Medicare beneficiaries/family members and nursing home staff that have agreed to participate in the Nursing Home Quality Improvement Peer Coaching Sessions. The population that will be targeted is the recruited and trained peer coaches in the TMF QON-QIO region.


TYPE OF COLLECTION: (Check one)


[ ] Customer Comment Card/Complaint Form [ ] Customer Satisfaction Survey

[ ] Usability Testing (e.g., Website or Software [ ] Small Discussion Group

[ ] Focus Group [x] Other: response to questions via Email

with link to Survey Monkey


CERTIFICATION:


I certify the following to be true:

  1. The collection is voluntary.

  2. The collection is low-burden for respondents and low-cost for the Federal Government.

  3. The collection is non-controversial and does not raise issues of concern to other federal agencies.

  4. The results are not intended to be disseminated to the public.

  5. Information gathered will not be used for the purpose of substantially informing influential policy decisions.

  6. The collection is targeted to the solicitation of opinions from respondents who have experience with the program or may have experience with the program in the future.


Name:_Patty Rawlings, COR, Division of Quality Improvement________________





To assist review, please provide answers to the following question:


Personally Identifiable Information:

  1. Is personally identifiable information (PII) collected? [ ] Yes [x] No

  2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ ] No

  3. If Yes, has an up-to-date System of Records Notice (SORN) been published? [ ] Yes [ ] No


Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [x] No





BURDEN HOURS


Category of Respondent

No. of Respondents

Participation Time

Burden

Nursing Home staff [additional recruits pending]

30

10

5

Beneficiary/family members [additional recruits pending]

6

10

1

Totals

36

20

6


FEDERAL COST: The estimated annual cost to the Federal government is $0.00


If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:


The selection of your targeted respondents

  1. Do you have a customer list or something similar that defines the universe of potential respondents and do you have a sampling plan for selecting from this universe? [ ] Yes [x] No


If the answer is yes, please provide a description of both below (or attach the sampling plan)? If the answer is no, please provide a description of how you plan to identify your potential group of respondents and how you will select them?


Per the QIN-QIO 11th SOW contract TMF is required to recruit volunteer nursing home staff and beneficiary/family members to be Peer Coaches. Individuals are recruited that are available and qualified to share information in keeping with the curriculum of the Peer Coaching Program. Peer Coaches will be paired with nursing homes that need improvement, activities, or opportunities where their knowledge may positively impact participating providers. Acquiring the requested information will allow the QIN-QIO to implement strategic approaches in maximizing these efforts. Additional coaches will be recruited. Sampling of the population will not occur. Information gathered is specific to the individual providing the data, and due to the nature by which the information will be utilized, it is necessary to use the entire population in this assessment. Questions being utilized are based on subjective information.


The intended use of the information gathered will drive communication with the peer coaches and provide a solid basis for ideal pairing in peer coaching opportunities. Peer Coaches are trained on the required topics, and selected from high-performing nursing homes. In the event that peer coaches do not excel in a topic area that has been chosen by the peer coach, individual assessment and analysis for this will occur in order to provide an enhanced opportunity for those receiving the training.



Administration of the Instrument

  1. How will you collect the information? (Check all that apply)

[ ] Web-based or other forms of Social Media

[x] Telephone

[ ] In-person

[ ] Mail

[x] Other; email containing a link to Survey Monkey

  1. Will interviewers or facilitators be used? [ ] Yes [x] No

Please make sure that all instruments, instructions, and scripts are submitted with the request.

Instructions for completing Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback”


TITLE OF INFORMATION COLLECTION: Provide the name of the collection that is the subject of the request. (e.g. Comment card for soliciting feedback on xxxx)


PURPOSE: Provide a brief description of the purpose of this collection and how it will be used. If this is part of a larger study or effort, please include this in your explanation.


DESCRIPTION OF RESPONDENTS: Provide a brief description of the targeted group or groups for this collection of information. These groups must have experience with the program.


TYPE OF COLLECTION: Check one box. If you are requesting approval of other instruments under the generic, you must complete a form for each instrument.


CERTIFICATION: Please read the certification carefully. If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved.


Personally Identifiable Information: Provide answers to the questions. Note: Agencies should only collect PII to the extent necessary, and they should only retain PII for the period of time that is necessary to achieve a specific objective.


Gifts or Payments: If you answer yes to the question, please describe the incentive and provide a justification for the amount.


BURDEN HOURS:

Category of Respondents: Identify who you expect the respondents to be in terms of the following categories: (1) Individuals or Households;(2) Private Sector; (3) State, local, or tribal governments; or (4) Federal Government. Only one type of respondent can be selected per row.

No. of Respondents: Provide an estimate of the Number of respondents.

Participation Time: Provide an estimate of the amount of time required for a respondent to participate (e.g. fill out a survey or participate in a focus group)

Burden: Provide the Annual burden hours: Multiply the Number of responses and the participation time and divide by 60.


FEDERAL COST: Provide an estimate of the annual cost to the Federal government.


If you are conducting a focus group, survey, or plan to employ statistical methods, please provide answers to the following questions:


The selection of your targeted respondents. Please provide a description of how you plan to identify your potential group of respondents and how you will select them. If the answer is yes, to the first question, you may provide the sampling plan in an attachment.


Administration of the Instrument: Identify how the information will be collected. More than one box may be checked. Indicate whether there will be interviewers (e.g. for surveys) or facilitators (e.g., for focus groups) used.


Submit all instruments, instructions, and scripts are submitted with the request.


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File Typeapplication/msword
File TitleDOCUMENTATION FOR THE GENERIC CLEARANCE
Author558022
Last Modified ByWILLIAM PARHAM
File Modified2015-06-02
File Created2015-06-02

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