Matter of Balance One Pager

Request for Approval under the “Fast Track Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery”

(OMB Control Number: 0704-0553)

TITLE OF INFORMATION COLLECTION: “Matter of Balance” Program

PURPOSE:

The "Matter of Balance" program is a health initiative designed to reduce fear of falling and increase activity levels among older adults.

The purpose of this interview guide is to obtain qualitative data about the “Matter of Balance” program. It is designed to understand experiences, perceptions, and outcomes of participants, to identify areas of success, and highlight opportunities for improvement. It will also help ensure participant-centered care and meet their needs and preferences. The goal is to obtain qualitative feedback and to guide any changes to the Evidence-Based Practice Quality Improvement program being implemented.

DESCRIPTION OF RESPONDENTS: Elderly individuals aged 65 years or older with a fall risk undergoing fall screening and prevention education.

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:_Jessica Vergara MSN, APRN, AGACNP-BC, FNP-BC, FNP-C, CCRN

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 [ x] No

3. If Yes, has an up-to-date System of Records Notice (SORN) 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

BURDEN HOURS

Category of Respondent	No. of Respondents	Participation Time	Burden
Individuals	48	20 min	16 hours
Totals	48	20 min	16 hours

PUBLIC COST: The estimated annual cost to the public is $116.00.

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?

The potential group of respondents are those who were referred to or voluntarily signed up for the fall prevention program courses. They would fall under the trauma surgery department list as patients who underwent fall screening and prevention.

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

[ ] Other, Explain

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

3