Generic Clearance Statement_CNH Dementia ECHO Educ_May 2019

Community Nursing Home (CNH) Dementia ECHO: An Interactive Educational Series

OMB No. 2900-0770
Estimated Burden: 10 minutes

Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 10 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this telephone/mail survey will lead to improvements in the quality of service delivery by helping to achieve contracted nursing home services. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number: 2900-0770)

T ITLE OF INFORMATION COLLECTION: Sense of Competence in Dementia Care Staff (SCIDS) Scale, demographics, and session evaluation for soliciting feedback on presentation and group discussion.

PURPOSE:

Educational offerings and staff support are often limited in rural Community Nursing Homes (CNH). These CNH are critical to serving the long-term support needs of Veterans with chronic physical and mental health conditions. The provision of such resources is imperative, given that the Veterans’ Health Administration (VHA) has shifted from providing nursing home care in VHA facilities towards purchasing care through contracts with CNHs. The physical burden of transportation and time contributes to limited opportunities for staff to benefit from resources including education and support and ultimately affects Veteran care.

To increase continuous access to resources, particularly to rural CNHs, we propose the provision of a virtual and interactive educational series for CNH staff. Furthermore, we aim for this educational series to be relevant specifically to CNHs in the State of Colorado and complement existing education and staff training by providing Veteran-centered content. Therefore, we will design this series based on the specific areas of interest and needs provided from the staff members of the CNH who are most familiar with the challenges of caring for Veterans with dementia at their site.

We wish to evaluate this process by using the SCIDS scale and a session evaluation to better understand the needs of the CNH staff as well as the usefulness of this program to them.

The goals of the project are:

Aim 1: Based on the needs of CNH staff, deliver a longitudinal educational series to improve care for Veterans living with dementia.

Aim 2: Evaluate and iteratively refine the educational series.

DESCRIPTION OF RESPONDENTS:

Respondents will include community nursing home staff including; social workers, coordinators, nurses, CNAs, physical and occupational therapists, etc.

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, Position Title and Credentials: __Emily Galenbeck, Research Assistant, B.A. _______

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 (R)	No. of Respondents	Participation Time	Burden (hours)
Individuals (questionnaire/survey)	120	10 min	20
Individuals (informal phone interview)	30	10 min	5
Totals	150	10 min per R	25

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? [ ] 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?

Administration of the Instrument

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

[ ] Web-based or other forms of Social Media

[ x] Telephone

[ ] In-person

[ x] 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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