Supporting Statement

Request for Approval under the “Generic Clearance for the Collection of Routine Customer Feedback” (OMB Control Number:0935-0179)

TITLE OF INFORMATION COLLECTION:

Request for Opioid Project Information from Patient Safety Organizations (PSOs)

PURPOSE:

The Agency for Healthcare Research and Quality (AHRQ) seeks feedback from AHRQ-listed PSOs (see respondent description below) on their interest in and current participation in opioid-related projects. The information gathering sheet will aid in the planning of a one-day PSO Summit on Opioid tools and projects in November of 2018. The Summit is a closed meeting of PSOs. Opioids are a top priority of the department, and both AHRQ and the AHRQ-listed PSOs are interested in finding ways to improve the crisis we now face across the country.

DESCRIPTION OF RESPONDENTS:

All respondents will be currently-listed AHRQ PSOs, and no personally identifiable individual information will be collected. Currently there are 82 PSOs nationwide; a sub-set are interested in or are currently working on opioid-related projects. We expect about 40 PSOs to respond with information on opioid projects they are or have worked on in the past. The majority of respondents are likely to be those attending the Summit in November. Since all respondents will be AHRQ-listed PSOs, AHRQ already has the contact information for each of these entities which is required for listing by AHRQ.

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: Feedback on current and past projects to aid in the development of the agenda for the November 2018 Opioid Summit

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: Tahleah Chappel

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 [ x ] No

3. If Applicable, has a System or Records Notice been published? [ ] Yes [ x] No

Gifts or Payments:

Is an incentive (e.g., money or reimbursement of expenses, token of appreciation) provided to participants? [ ] Yes [ X] No

Category of Respondent: Private Sector

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
	40	10 minutes	6.6 hours
Totals	40	10 minutes	6.6 hours

FEDERAL COST: The estimated annual cost to the Federal government is $689.13, which includes 1) $243.83 in instrument development and 2) $445.30 in project management and oversight. There are no direct costs to respondents other than their time to complete the information collection form.

Grade	Number of Hours	Value
GS 13	3	171.72
GS 15	2	159.12
Contractor	4	358.29
Total		689.13

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? [ x] Yes [ ] 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?

AHRQ has an email distribution list which includes only the AHRQ-listed PSO points of contact. This is the list that will be used to send out the information collection form. Each member on the distribution list will receive an email so that all PSOs are contacted about the opportunity to participate.

Administration of the Instrument

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

[ x ] Web-based or other forms of Social Media

[ ] Telephone

[ ] In-person

[ ] Mail

[ ] Other, Explain

2. Will interviewers or facilitators be used? [ ] Yes [ x ] No