Workplace Violence Prevention Programs In New Jersey Healthcare Facilities

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
Form 0920-0914 Nursing Home Administrators Committee Chair Interview	Form	Unchanged	Available
Form 0920-0914 Nursing Home Administrators Committee Chair Interview	Form	Modified	Available
Form 0920-0914 Nursing Home Administrators Survey	Form	Unchanged	Available
Request for NonsubstantiveChange 0920-0914.docx	Justification for No Material/Nonsubstantive Change	Uploaded 2018-08-28	Available
Appendix G.rtf	Supplementary Document	Uploaded 2018-03-26	Available
Appendix F.pdf	Supplementary Document	Uploaded 2018-03-26	Available
Appendix E.pdf	Supplementary Document	Uploaded 2018-02-26	Available
Appendix D.docx	Supplementary Document	Uploaded 2018-03-26	Available
Appendix B.pdf	Supplementary Document	Uploaded 2018-02-26	Available
Appendix A.docx	Supplementary Document	Uploaded 2018-03-26	Available
Supporting Statement B 3.26.18.doc	Supporting Statement B	Uploaded 2018-03-26	Available
Sup Sta A 0920-0914 3.28.18.docx	Supporting Statement A	Uploaded 2018-03-28	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
205004	Nursing Home Administrators Committee Chair Interview	Form	Unchanged
205003	Nursing Home Administrators Committee Chair Interview	Form	Modified
205002	Nursing Home Administrators Survey	Form	Unchanged

ICR Details

OMB Control No: 0920-0914	ICR Reference No: 201808-0920-007
Status: Historical Inactive	Previous ICR Reference No: 201802-0920-010
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-0914-18AVI
Title: Workplace Violence Prevention Programs In New Jersey Healthcare Facilities
Type of Information Collection: No material or nonsubstantive change to a currently approved collection	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Improperly submitted and continue	Conclusion Date: 10/18/2018
	Date Received in OIRA: 09/11/2018
Terms of Clearance: Revised modes of data collection (in this case, switching to an electronic submission system) must be submitted through a revision request. New modes of data collection including changes in methods/platform entail re-review of privacy and IT security issues.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	05/31/2019	05/31/2019	06/30/2019
Responses	60	0	60
Time Burden (Hours)	60	0	60
Cost Burden (Dollars)	0	0	0

---

Abstract: This project is an intervention evaluation study, comparing the comprehensiveness of nursing home workplace violence prevention programs in New Jersey (NJ) with the comprehensiveness of programs in Virginia (VA). The purpose of the information collected is to disseminate the information to health departments for potential development of legislation for a workplace violence prevention programs. We are requesting a change to the method of collecting the survey data for one instrument to an online survey due to difficulty recruiting nursing home workplace violence prevention committee chairs to do an in person interview.

---

Authorizing Statute(s): PL: Pub.L. 91 - 596 20.a.1 Name of Law: Occupational Safety and Health Act
  

Citations for New Statutory Requirements: None

---

Associated Rulemaking Information
RIN:	Stage of Rulemaking:	Federal Register Citation:	Date:
	Not associated with rulemaking

---

Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	82 FR 55611	11/22/2017
30-day Notice:	Federal Register Citation:	Citation Date:
	83 FR 12764	03/23/2018
Did the Agency receive public comments on this ICR? Yes

---

Number of Information Collection (IC) in this ICR: 3

table that charts list of burden

IC Title	Form No.	Form Name
Nursing Home Administrators Survey	0920-0914	Evaluation of Nursing Home Workplace Violence Prevention Program Abstraction Form
Nursing Home Administrators Committee Chair Interview	0920-0914, 0920-0914	Committee Chair Interview Online ,   Committee Chair Interview
Nursing Home Administrators Committee Chair Interview	0920-0914	Employee Incident

---

Burden increases because of Program Change due to Agency Discretion: No

Burden Increase Due to:

Burden decreases because of Program Change due to Agency Discretion: No

Burden Reduction Due to:

Short Statement:

---

Annual Cost to Federal Government: $0

Does this IC contain surveys, censuses, or employ statistical methods? Yes Part B of Supporting Statement

Does this ICR request any personally identifiable information (see OMB Circular No. A-130 for an explanation of this term)? Please consult with your agency's privacy program when making this determination.     No

Does this ICR include a form that requires a Privacy Act Statement (see 5 U.S.C. §552a(e)(3))? Please consult with your agency's privacy program when making this determination.     No

Is this ICR related to the Affordable Care Act [Pub. L. 111-148 & 111-152]? No

Is this ICR related to the Dodd-Frank Wall Street Reform and Consumer Protection Act, [Pub. L. 111-203]? No

Is this ICR related to the American Recovery and Reinvestment Act of 2009 (ARRA)? No

Is this ICR related to the Pandemic Response? Uncollected

---

Common Form ICR:  No

---

On behalf of this Federal agency, I certify that the collection of information encompassed by this request complies with 5 CFR 1320.9 and the related provisions of 5 CFR 1320.8(b)(3).

The following is a summary of the topics, regarding the proposed collection of information, that the certification covers:

(a) It is necessary for the proper performance of agency functions;

(b) It avoids unnecessary duplication;

(c) It reduces burden on small entities;

(d) It uses plain, coherent, and unambiguous language that is understandable to respondents;

(e) Its implementation will be consistent and compatible with current reporting and recordkeeping practices;

(f) It indicates the retention periods for recordkeeping requirements;

(g) It informs respondents of the information called for under 5 CFR 1320.8 (b)(3) about:

(i) Why the information is being collected;

(ii) Use of information;

(iii) Burden estimate;

(iv) Nature of response (voluntary, required for a benefit, or mandatory);

(v) Nature and extent of confidentiality; and

(vi) Need to display currently valid OMB control number;

(h) It was developed by an office that has planned and allocated resources for the efficient and effective management and use of the information to be collected.

(i) It uses effective and efficient statistical survey methodology (if applicable); and

(j) It makes appropriate use of information technology.

If you are unable to certify compliance with any of these provisions, identify the item by leaving the box unchecked and explain the reason in the Supporting Statement.

Certification Date: 09/11/2018

---