Information Collection

Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum

IC 222551 under ICR 202009-0935-002 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 2 2. Appendix B – Moderator Guide 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

IC Title:

Focus Groups on TeamSTEPPSÂ® for Long-Term Care Curriculum

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Available Electronically?	Electronic Capability
Form and Instruction	2	No	Paper Only
Other-screener		No	Paper Only
Other-Feedback		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 %

table that charts list of burden
	Requested	Previously Approved
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

table that charts IC Documents
Title	Document	Date Uploaded
4. Appendix D â List of Module Names to be Used in Focus Groups		07/20/2016
Module 2		07/20/2016
Module 3		07/20/2016
Module 4		07/20/2016
Module 5		07/20/2016
Module 6		07/20/2016
Module 8		07/20/2016
Module 10		07/20/2016
Module 11		07/20/2016
Cover Memo		07/20/2016
Supporting Statement A		07/20/2016
Supporting Statement B		07/20/2016

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

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