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	Removed	Available
Employee Incident	Form	Modified	Available
Committee Chair Interview	Form	Modified	Available
Evaluation of Nursing Home Workplace Violence Prevention Program Abstraction Form	Form	Modified	Available
Nurse Survey	Form	Removed	Available
Incident Information	Form	Removed	Available
Interview	Form	Removed	Available
Evaluation Form	Form	Removed	Available
Appendix G .docx	Supplementary Document	Uploaded 2015-10-26	Available
Appendix F.docx	Supplementary Document	Uploaded 2015-10-26	Available
Att E IRB.pdf	Supplementary Document	Uploaded 2015-10-26	Available
Appendix D.docx101915.docx	Supplementary Document	Uploaded 2015-10-26	Available
Att B 60-Day.pdf	Supplementary Document	Uploaded 2015-10-26	Available
Appendix A.docx	Supplementary Document	Uploaded 2015-10-26	Available
Responses Statement B revised_3.23.docx	Supporting Statement B	Uploaded 2016-03-23	Available
Responses Statement A revised_3.23.docx	Supporting Statement A	Uploaded 2016-03-24	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205005	Home Healthcare Aides Survey	Form	Removed	Home Healthcare Aide Survey
205004	Nursing Home Administrators Committee Chair Interview	Form	Modified	Employee Incident
205003	Nursing Home Administrators Committee Chair Interview	Form	Modified	Committee Chair Interview
205002	Nursing Home Administrators Survey	Form	Modified	Evaluation of Nursing Home Workplace Violence Prevention Program Abstraction Form
199796	Nurse (RN and LPN) Survey	Form	Removed	Nurse Survey
199795	Hospital Administrators Employee Incident Information	Form	Removed	Incident Information
199794	Hospital Administrators Committee Chair Interview	Form	Removed	Interview
199793	Hospital Administrators Evaluation Form	Form	Removed	Evaluation Form

ICR Details

OMB Control No: 0920-0914	ICR Reference No: 201510-0920-006
Status: Historical Active	Previous ICR Reference No: 201403-0920-011
Agency/Subagency: HHS/CDC	Agency Tracking No:
Title: Workplace Violence Prevention Programs In New Jersey Healthcare Facilities
Type of Information Collection: Revision of a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 03/24/2016
Retrieve Notice of Action (NOA)	Date Received in OIRA: 11/04/2015
Terms of Clearance: Approved consistent with the understanding that the following limitations will be addressed in any publications or presentations: 1) most of the information will be collected through self-report, which could lead to reporting bias and the misclassification of the presence of workplace violence prevention program components; 2) differential response rates between New Jersey and Virginia could introduce a bias; 3) assessment of the quality of the components will not be conducted.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	03/31/2018	24 Months From Approved	03/31/2016
Responses	60	0	2,738
Time Burden (Hours)	60	0	960
Cost Burden (Dollars)	0	0	0

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Abstract: This is an intervention evaluation study to compare the comprehensiveness of nursing home workplace violence prevention programs in New Jersey to those in Virginia. This revision is to complete, and add, nursing home interviews and drop the nursing home administrator employee incident information form. The remainder of the study was completed over the past three years.

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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
60-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 16391	03/27/2015
30-day Notice:	Federal Register Citation:	Citation Date:
	80 FR 65763	10/27/2015
Did the Agency receive public comments on this ICR? No

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Number of Information Collection (IC) in this ICR: 3

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	none	Committee Chair Interview
Nursing Home Administrators Committee Chair Interview	none	Employee Incident
Nursing Home Administrators Survey	none	Evaluation of Nursing Home Workplace Violence Prevention Program Abstraction Form

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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	60	2,738	0	-2,678	0	0
Annual Time Burden (Hours)	60	960	0	-900	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: Yes

Burden Reduction Due to: Miscellaneous Actions

Short Statement: Most of the information collection for this study was completed over the past three years of approval. This revision request is for 2 years to complete, and add, nursing home administrator interviews, and to drop the Employee Incident Information Form. There is a decrease in burden due to completed collections, and a slight increase as 20 additional nursing homes are included.

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Annual Cost to Federal Government: $19,612

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: 11/04/2015

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