Memo Feedback

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

T ITLE OF INFORMATION COLLECTION: Peer Support and Pain Self-Management Education Program Feedback

PURPOSE: Data collection to be used in program evaluation to determine if need for opioid medications and feelings in general toward life have changed for participants in Chronic Pain Self-Management Program workshops and/or Peer Support.

The purpose of this research project is to conduct a program evaluation for Women Rise: Empowering women to manage pain, a program of the Partnership for the Prevention of Opioid Misuse in Women in the Central Shenandoah Valley (WR). The Sentara Quality Research Institute (SQRI) will provide reports, based on available data, to the Office on Women’s Health (OWH) of the United States Department of Health and Human Services (HHS) that WR used funds received to provide training and services that were described in their grant proposal including: 1) Continuing Medical Education (CME) opportunities and support for prescribing providers; 2) evidence- based Chronic Pain Self-Management Program for women; 3) evidence-based, state certified Peer Support Specialists in primary care clinics; and 4) medication disposal efforts. SQRI will also evaluate whether the efforts affected the number of Opioid prescriptions provided to women in our community which may prevent Opioid misuse in women who experience chronic pain and/or other stressful situations.

Certification #4, “The results are not intended to be disseminated to the public”, is incorrect for this grant for Sentara RMH Medical Center. Prior to beginning the study we obtained approval from the SRMH Institution Review Board. Program evaluation data will be de-identified and reported in the aggregate to include dissemination to the public via channels such as poster presentations, scholarly publications, and reports to funders.

DESCRIPTION OF RESPONDENTS: Participants in the Chronic Pain Self-Management Program (CPSMP) workshops and Participants attending individual or group Peer Support (PS) sessions are invited to take the pre and post-tests.

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: Pre and Post-Test

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. – SEE ABOVE

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: Christine Woolslayer

To assist review, please provide answers to the following question:

Personally Identifiable Information:

1. Is personally identifiable information (PII) collected? [ X ] Yes [ ] No

2. If Yes, will any information that is collected be included in records that are subject to the Privacy Act of 1974? [ ] Yes [ X ] 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
Individuals participating in CPSMP or PS	66	20/60	22
Totals	66	20/60	22

FEDERAL COST: The estimated annual cost to the Federal government is _$175____

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?

All participants in Women Rise Chronic Pain Self-Management Program workshops and Peer Support sessions are invited to participate in the program evaluation by completing the pre and post-tests.

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 – Paper Copy Form to be completed on site

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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