Memo

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” HHS Communications (OMB Control Number: 0990-0459

TITLE OF INFORMATION COLLECTION:

Opioid Care Coordination Consultation Meetings Feedback

PURPOSE:

Between 1999 and 2015, Opioid Use Disorder (OUD) overdoses and heroin related deaths among women have increased at greater rate compared to men.¹ To address the prevalence of prescription opioid and heroin use among women the Department of Health and Human Services under Health Resources and Services Administration, HRSA and Office of Women’s Health, OWH , are in partnership and in consultation with the HRSA Office of Regional Operations and the Substance Abuse and Mental Health Administration (SAMHSA) is launching a Regional Opioid Consultation Initiative to develop Family Centered Treatment and Care Coordination Models for Women Served by HRSA Programs. This initiative is comprised of six working consultation meetings that will bring stakeholders together to develop the Care Coordination Model for Women:

• Meeting 1 (Rockville, MD): February 5, 2019

• Meeting 2 (Kansas City, MO): March 14, 2019

• Meeting 3 (San Francisco, CA): May 29, 2019

• Meeting 4-6: Dates in 2020 to be determined.

HHS OWH has contracted with NORC to evaluate the extent to which these meetings engage and establish partnerships among stakeholders; identify and share promising practices, innovations and recommendations to address the opioid crisis and needs of women; and determine the components of a care coordination model supporting women impacted by the opioid crisis.

Gathering participant feedback through a post-meeting feedback form (the form will be offered in paper and electronic format) will be essential for understanding participants’ perspectives on whether they felt the meeting was conducted in an open and unbiased manner; the extent to which participants’ felt prepared and engaged and understood their roles; the organization and productiveness of the meeting; whether other attendees represented regional stakeholders and decision-makers on opioid use disorder issues for women; and overall satisfaction with the meeting. While meeting evaluators will ascertain some of these pieces of information through meeting observation, participant perspectives will be vital for a full understanding of whether the meeting was successful. The information gathered from each meeting will be used to inform the approach to each subsequent meeting.

After each meeting, NORC will field the paper and pencil post-meeting feedback form and request participants to complete and return the form to NORC staff before leaving the meeting. Participants will complete the form and not include their name or any identifying information on the form. The instrument will include Likert scale questions asking the extent to which participants agree or disagree with statements to assess as well as several open-ended questions.

DESCRIPTION OF RESPONDENTS:

Respondents will consist of regional stakeholders and decision-makers on opioid use disorder issues for women, including physicians, social workers, local and state health officials, social service providers, and representatives of consumer advocacy groups. We estimate that there will be 16 participants from the private sector at each meeting, for a total of 96 non-federal participants across the six meetings.

TYPE OF COLLECTION: (Check one)

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

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

[] Focus Group [] Other:

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:__Kara L Beck____________________________________

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

3. If Applicable, has a System or Records Notice 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 hour
Private Sector	96	5/60	8

FEDERAL COST:

Based on contractor cost and federal employee time, the cost to the federal government is estimated to be $25,259.70.

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?

The respondents will consist of all individuals who attend each of the regional consultation meetings.

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ ] Telephone

[X] In-person

[ ] Mail

[X] Other, Explain

In the event that there is not sufficient time for participants to complete the feedback form at the end of the meeting, evaluators will follow up with participants via email to request that they complete the form and send it back.

2. 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.

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.

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.

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

1 Final Report: Opioid Use, Misuse, and Overdose in Women. July 19, 2017. U.S. Department of Health and Human Services, Office on Women’s Health. https://www.womenshealth.gov/files/documents/final-report-opioid-508.pdf. Last Accessed December 18, 2018.

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