Surveys for Building Your Wellness Toolbox (A six week psycho-educational group as part of the Promoting Older Women’s Engagemen

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

TITLE OF INFORMATION COLLECTION:

Surveys for Building Your Wellness Toolbox (A six week psycho-educational group as part of the Promoting Older Women’s Engagement in Recovery project)

PURPOSE:

These surveys are part of the Promoting Older Women’s Engagement in Recovery (POWER) project being run by the Institute for Health and Recovery (IHR), located in Cambridge MA. POWER is funded through a prevention grant from the Office on Women’s Health. The project is focused on preventing opioid misuse and abuse in women ages 55 and up (55+), in the Massachusetts’ cities of Cambridge and Somerville.

As part of POWER, we are running a six week psycho-educational group for older women entitled “Building Your Wellness Toolbox: Managing Stress, Pain and Medication.” The group focuses on stress reduction, pain management options, and medication safety. The group is an open format, meaning new participants can join for any session.

This submission includes six mini surveys, one to correspond with each of the six sessions of the group. The paper surveys will be distributed at the end of each session for the participants to complete immediately and hand back. No identifying information will be included on the surveys themselves. The group facilitator will review the surveys immediately upon receipt to note if any participants checked the boxes about requiring further follow up. Group facilitators will make separate notes for themselves pertaining to the need for follow up with individuals, and then the surveys will be stored with no identifying information included.

Participants will be encouraged to complete the surveys and provide comments if they like, and the surveys are designed to be time efficient, but participation remains voluntary. We will use feedback gained from these surveys to continue to improve future renditions of this group to make sure the appropriate outcomes of the project are being met.

DESCRIPTION OF RESPONDENTS:

Participants will consist of women above the age of 55 who choose to participate in this group. We will be offering this group in multiple locations, including senior centers in both Cambridge and Somerville. Participants will be any woman, who upon learning about the group, decides to join the group and participates in at least one session. There are no other pre-requisites for joining this group, aside from being someone who identifies as a woman and is 55 years of age or older.

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: Post Group 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: Laurie Robinson_, RWHC Region I OASH, US DHHS

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
Session 1 Participants	30	7/60	3.5
Session 2 Participants	25	8/60	3.3
Session 3 Participants	20	8/60	2.6
Session 4 Participants	20	10/60	3.3
Session 5 Participants	18	9/60	2.7
Session 6 Participants	18	7/60	2.1
Totals			17.5

*Participation time estimates are based on the average time taken to complete the surveys by a small sample group. Number of respondents based on projections for the number of participants in the upcoming 12 month grant period.

FEDERAL COST: The estimated annual cost to the Federal government is $575____

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?

As part of POWER, IHR is partnered with a number of organizations in the community who work directly with women ages 55+. IHR will be hosting this group at partner organization sites and other community based sites. The host sites will be doing the outreach and advertising for these groups. Any respondent is welcome as long as they identify as a woman, are 55 years of age or older, and have participated in one group session. All participants that attend any of the group sessions will be provided a survey at the end of the group session.

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

[ ] 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.

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.

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