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Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 0990-0379)

T ITLE OF INFORMATION COLLECTION:

Rowan University School of Osteopathic Medicine (SOM):

• Opioid Prescribing Presentation Pre Assessment

• Opioid Prescribing Presentation Post Assessment

• Opioid Prescribing Presentation Satisfaction Survey

PURPOSE:

Rowan University School of Osteopathic Medicine (SOM) will implement primary and secondary prevention activities to prevent opioid misuse and overdose in predominantly Caucasian women between the ages of 25 and 59 who are taking opiates for chronic pain. The purpose of this study is to research best practices for pain education curricula, develop an evidence-based curriculum focusing on improving opiate prescribing for women, and create core competencies for opioid prescription education for the School of Osteopathic Medicine of Rowan University.

In order to continuously improve upon opioid education, the following survey tools will be used:

1. Opioid Prescribing Presentation Pre Assessment – the purpose of this survey is to measure provider knowledge and attitudes.

2. Opioid Prescribing Presentation Post Assessment – the purpose of this survey is to measure provider knowledge and attitudes.

3. Opioid Prescribing Presentation Satisfaction Survey – the purpose of this survey is to measure participant satisfaction with course materials and training.

This program is funded through a prevention grant from the U.S. Department of Health and Human Services (HHS), Office on Women’s Health (OWH).

DESCRIPTION OF RESPONDENTS:

1. Third Year Medical Students at Rowan School of Osteopathic Medicine

2. Residents at Rowan Medicine, Rowan School of Osteopathic Medicine

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:

1. Pre Assessment Survey

2. Post Assessment Survey

3. Satisfactory Survey

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:____Marline Vignier ________________________________

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
Medical Students (Individuals)_Pre Assessment	40	5 / 60	3.33
Medical Students (Individuals)_Post Assessment	40	5 / 60	3.33
Medical Students (Individuals)_Satisfactory Survey	40	5 / 60	3.33
Residents (Individuals)_Pre Assessment	60	5 / 60	5.0
Residents (Individuals)_Post Assessment	60	5 / 60	5.0
Residents (Individuals)_Satisfaction Survey	60	5 / 60	5.0
Totals			24.99

FEDERAL COST: The estimated annual cost to the Federal government is ___ $0 _____

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? [ X ] Yes [ ] 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?

1. The Opioid Prescribing Presentation Pre/Post Assessment is designed to measure current knowledge, skills, and attitudes towards opioid prescribing practices. In addition, changes in physician knowledge and attitudes will be measured. The Project Co-Director will aggregate responses to the pre-/post-surveys, calculate total scores for each question, and compare results between the pre-survey and post-survey to determine their significance.

Sampling Plan: We plan to collect responses using Qualtrics and analyze the results using SPSS to run an independent T-test to compare two groups, the control (no intervention) and the experimental group (program intervention), which will yield a paired sample statistics output that is statistically significant (p < 0.05). We hypothesize that the knowledge scores will improve after program intervention.

2. The Opioid Prescribing Presentation Satisfaction Survey is designed to measure course satisfaction and fidelity of the training instructor for participants in our training course for opioid prescribing practices. The Project Co-Director will aggregate responses to the satisfaction survey, calculate total scores for each question, and evaluate satisfaction scores post intervention.

Sampling Plan: We plan to collect responses using Qualtrics and analyze the results using descriptive statistics. Our goal is to have 80% satisfaction in participant training.

Administration of the Instrument

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

[ X ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

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. 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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