Evaluation of Venous Thromboembolism Prevention Practices in U.S. Hospitals

Forms and Documents

Document Name	Status
Questionnaire Form	New
Att. 8 Non-research determination.pdf Supplementary Document	2021-02-23
Att. 7 Recruitment communications.pdf Supplementary Document	2021-02-23
Att. 6 Characteristics of pilot sites.pdf Supplementary Document	2021-02-23
Att. 5 Implementation email and project info sheet.pdf Supplementary Document	2021-02-23
Att. 2 60-day FRN.pdf Supplementary Document	2021-02-23
Att. 1 Authorizing Legislation.pdf Supplementary Document	2021-02-23
Supporting Statement Part B.docx Supporting Statement B	2021-02-23
Supporting Statement Part A_rev.docx Supporting Statement A	2021-02-23

IC Document Collections

IC ID	Document Title	Status
245946	Questionnaire Form	New

ICR Details

OMB Control No:	ICR Reference No: 202102-0920-012
Status: Received in OIRA	Previous ICR Reference No:
Agency/Subagency: HHS/CDC	Agency Tracking No: 0920-21AT
Title: Evaluation of Venous Thromboembolism Prevention Practices in U.S. Hospitals
Type of Information Collection: New collection (Request for a new OMB Control Number)	Common Form ICR:  No
Type of Review Request: Regular	Date Submitted to OIRA: 03/26/2021

	Requested	Previously Approved
Expiration Date	12 Months From Approved
Responses	384	0
Time Burden (Hours)	384	0
Cost Burden (Dollars)	18,643	0

---

Abstract: Venous thromboembolism (VTE) is an important and growing public health problem. The purpose of this project is to evaluate current VTE prevention practices in U.S. hospitals in order to support a framework for hospital-associated VTE prevention. A random sample of U.S. adult general medical/surgical hospitals will be asked to complete a questionnaire administered electronically through the QualtricsXM platform.

---

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

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:
	85 FR 73716	11/19/2020
30-day Notice:	Federal Register Citation:	Citation Date:
	86 FR 16214	03/26/2021
Did the Agency receive public comments on this ICR? No

---

Number of Information Collection (IC) in this ICR: 1

IC Title	Form No.	Form Name
Questionnaire	none	Evaluation of VT Prevention Practices

---

ICR Summary of Burden

	Total Request	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	384	0	0	384	0	0
Annual Time Burden (Hours)	384	0	0	384	0	0
Annual Cost Burden (Dollars)	18,643	0	0	18,643	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.

---

Annual Cost to Federal Government: $140,147

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? No

---

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: 03/26/2021

---