Evaluating the implementation and impact of an opioid medication management program, in a hospital discharge setting, to reduce falls in older adults

Forms and Documents

Forms and supporting documents for this ICR

Document	Type	Status	Availability
PCP post-discharge survey	Form	New	Available
Clinical staff questionnaire	Form	New	Available
Post-discharge Patient Questionnaire	Form	New	Available
Pre-discharge patient questionnaire	Form	New	Available
POMI-test-article.pdf	Supplementary Document	Uploaded 2020-02-10	Available
SAMHSA email.pdf	Supplementary Document	Uploaded 2020-02-10	Available
NCHS email.pdf	Supplementary Document	Uploaded 2020-02-10	Available
Crosswalk Post Patient Survey Questions.docx	Supplementary Document	Uploaded 2020-02-10	Available
Crosswalk Pre Patient Survey Questions.docx	Supplementary Document	Uploaded 2020-02-10	Available
Attachment H Patient Consent Form .docx	Supplementary Document	Uploaded 2019-10-21	Available
Attachment G3 Correspondence to primary care providers.docx	Supplementary Document	Uploaded 2019-10-21	Available
Attachment G2 Correspondence to UCSF clinical staff.docx	Supplementary Document	Uploaded 2019-10-21	Available
Attachment G1 Correspondence to patients.docx	Supplementary Document	Uploaded 2019-10-21	Available
Attachment F1. Illustrative table shells.xlsx	Supplementary Document	Uploaded 2019-10-21	Available
Attachment D IRB_Approval letter.pdf	Supplementary Document	Uploaded 2019-10-21	Available
Attachment C PIA.pdf	Supplementary Document	Uploaded 2019-10-21	Available
Attachment B 60 day FRN.pdf	Supplementary Document	Uploaded 2019-10-21	Available
Attachment A Authorizing Legislation.docx	Supplementary Document	Uploaded 2019-10-21	Available
SSB_Evaluating implementation fall prevention program 10.9.19.docx	Supporting Statement B	Uploaded 2019-10-21	Available
SSA_Evaluating implementation fall prevention program_10.21.19.docx	Supporting Statement A	Uploaded 2019-10-21	Available

IC Document Collections

Information collection document groups

IC ID	Collection	Type	Status	Form
238232	PCP post-discharge survey	Form	New
238231	Clinical staff questionnaire	Form	New
238230	Post-discharge Patient Questionnaire	Form	New
238229	Pre-discharge patient questionnaire	Form	New

ICR Details

OMB Control No: 0920-1285	ICR Reference No: 201910-0920-007
Status: Active	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-19GH
Title: Evaluating the implementation and impact of an opioid medication management program, in a hospital discharge setting, to reduce falls in older adults
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular
OIRA Conclusion Action: Approved with change	Conclusion Date: 02/11/2020
	Date Received in OIRA: 11/21/2019
Terms of Clearance: Approved consistent with the understanding that CDC will not be conducting any general research on the information collected. When communicating findings from this collection, all publications will clearly describe the scope and limitations of the study findings. CDC/NCIPC will continue to consult and work closely with SAMHSA and CDC/NCHS to harmonize opioid related data collections.

table that charts list comparision

	Inventory as of this Action	Requested	Previously Approved
Expiration Date	02/28/2023	36 Months From Approved
Responses	3,300	0	0
Time Burden (Hours)	541	0	0
Cost Burden (Dollars)	12,997	0	0

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Abstract: The goal of this data collection is to conduct a formative evaluation to inform CDC of best practices for implementation of a fall prevention program into the hospital discharge process targeting opioid prescribing and management.

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Authorizing Statute(s): US Code: 42 USC 241 Name of Law: PHSA
  

Citations for New Statutory Requirements: None

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

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Federal Register Notices & Comments
60-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 2520	02/07/2019
30-day Notice:	Federal Register Citation:	Citation Date:
	84 FR 64078	11/20/2019
Did the Agency receive public comments on this ICR? Yes

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Number of Information Collection (IC) in this ICR: 4

table that charts list of burden

IC Title	Form No.	Form Name
PCP post-discharge survey	none	PCP Post-discharge survey
Pre-discharge patient questionnaire	none	Pre-discharge questionnaire
Post-discharge Patient Questionnaire	none	Post-discharge patient questionnaire
Clinical staff questionnaire	none	Clinical Staff Questoinnaire

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ICR Summary of Burden

table that charts list of burden

	Total Approved	Previously Approved	Change Due to New Statute	Change Due to Agency Discretion	Change Due to Adjustment in Estimate	Change Due to Potential Violation of the PRA
Annual Number of Responses	3,300	0	0	3,300	0	0
Annual Time Burden (Hours)	541	0	0	541	0	0
Annual Cost Burden (Dollars)	12,997	0	0	12,997	0	0

Burden increases because of Program Change due to Agency Discretion: Yes

Burden Increase Due to: Miscellaneous Actions

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

Burden Reduction Due to:

Short Statement: This is a new ICR.

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Annual Cost to Federal Government: $66,313

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.     Yes

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.     Yes

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

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Common Form ICR:  No

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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: 11/21/2019

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