Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum

Generic Clearance for the Collection of Qualitative Feedback on Agency Service Delivery

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0179 can be found here:

Documents and Forms

Document Name Document Type
Form 2 Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum Form and Instruction
Appendix A - _Focus Group Screener Guide.docx Other-screener
Appendix C - Focus Group Feedback Sheet.docx Other-Feedback
2 2. Appendix B – Moderator Guide Appendix B - Moderator's Guide.docx Form and Instruction
Appendix D - List of Module naaes to be used in Focus Groups.docx 4. Appendix D – List of Module Names to be Used in Focus Groups IC Document
Module 2 - Instructor Guide.pdf Module 2 IC Document
Module 3 - Instructor Guide.pdf Module 3 IC Document
Module 4 - Instructor Guide.pdf Module 4 IC Document
Module 5 - Instructor Guide.pdf Module 5 IC Document
Module 6 - Instructor Guide.pdf Module 6 IC Document
Module_8.pdf Module 8 IC Document
Module 10 - Instructor Guide.pdf Module 10 IC Document
Module 11 - Instructor Guide.pdf Module 11 IC Document
OMB Cover Letter.doc Cover Memo IC Document
TS LTC Generic Clearance Submission Form SS Part A.doc Supporting Statement A IC Document
TS for LTC OMB Supporting Statement Part B 7-18-16.docx Supporting Statement B IC Document

Information Collection (IC) Details

IC Title:	Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum	Agency IC Tracking Number:

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	2	2. Appendix B – Moderator Guide	Appendix B - Moderator's Guide.docx	No	Paper Only
Other-screener			Appendix A - _Focus Group Screener Guide.docx	No	Paper Only
Other-Feedback			Appendix C - Focus Group Feedback Sheet.docx	No	Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 72	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
4. Appendix D – List of Module Names to be Used in Focus Groups	Appendix D - List of Module naaes to be used in Focus Groups.docx	07/20/2016
Module 2	Module 2 - Instructor Guide.pdf	07/20/2016
Module 3	Module 3 - Instructor Guide.pdf	07/20/2016
Module 4	Module 4 - Instructor Guide.pdf	07/20/2016
Module 5	Module 5 - Instructor Guide.pdf	07/20/2016
Module 6	Module 6 - Instructor Guide.pdf	07/20/2016
Module 8	Module_8.pdf	07/20/2016
Module 10	Module 10 - Instructor Guide.pdf	07/20/2016
Module 11	Module 11 - Instructor Guide.pdf	07/20/2016
Cover Memo	OMB Cover Letter.doc	07/20/2016
Supporting Statement A	TS LTC Generic Clearance Submission Form SS Part A.doc	07/20/2016
Supporting Statement B	TS for LTC OMB Supporting Statement Part B 7-18-16.docx	07/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.