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	Unchanged	Available
Nursing Home Administrators Employee Incident Information	Form	Unchanged	Available
Form 0920-0914 Nursing Home Administrators Survey	Form and Instruction	Modified	Repair queued
Nurse (RN and LPN) Survey	Form	Unchanged	Repair queued
Hospital Administrators Employee Incident Information	Form	Unchanged	Available
Hospital Administrators Committee Chair Interview	Form	Unchanged	Available
Form 0920-0914 Hospital Administrators Evaluation Form	Form and Instruction	Modified	Available
OMB Change 7-21-15-final.doc	Justification for No Material/Nonsubstantive Change	Uploaded 2015-07-28	Repair queued

IC Document Collections

Information collection document groups

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

ICR Details

OMB Control No: 0920-0914	ICR Reference No: 201507-0920-011
Status: Historical Inactive	Previous ICR Reference No: 201403-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No: 15AJV
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: Improperly submitted and continue	Conclusion Date: 08/03/2015
	Date Received in OIRA: 07/28/2015
Terms of Clearance:

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/29/2016	02/29/2016	03/31/2016
Responses	2,738	0	2,738
Time Burden (Hours)	960	0	960
Cost Burden (Dollars)	0	0	0

---

Abstract: NIOSH is requesting a nonmaterial/non-substantive change to our OMB Information Collection Request titled 'Workplace Violence Prevention Programs in NJ Healthcare Facilities' (OMB control number 0920-0914, expiration date 2/29/2016). In order to learn about safety climates in hospitals and nursing homes, we would like to request a change to Attachment C1: Hospital and Nursing Home – Evaluation of Workplace violence Prevention Program. We would like to add the Organizational-level Safety Climate questions (Section I. 1-16) to the data collection instrument.

---

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

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments

Did the Agency receive public comments on this ICR? Yes

---

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

table that charts list of burden

IC Title	Form No.	Form Name
Hospital Administrators Evaluation Form	0920-0914	Attachment C1 Cleant
Hospital Administrators Committee Chair Interview	none	Interview
Hospital Administrators Employee Incident Information	none	Incident Information
Nurse (RN and LPN) Survey	none	Nurse Survey
Nursing Home Administrators Survey	0920-0914	Attachment C1
Nursing Home Administrators Committee Chair Interview
Nursing Home Administrators Employee Incident Information	none	Employee Incident
Home Healthcare Aides Survey	none	Home Healthcare Aide Survey

---

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: . The burden hours will increase by 2 hours, going from 960 burden hours to 962 since the safety climate questions (Section I 1-16) take approximately 5 minutes to answer. The interview time went from 60 minutes to 65 minutes (1.08 hours).

---

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

---

Common Form ICR:  No

---

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: 07/28/2015

---