Team Checkup Tool

The AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0260 can be found here:

Documents and Forms

Document Name Document Type
Form 6 Team Checkup Tool Form and Instruction
6 Attachment E: ICU/Non-ICU Team Checkup Tool Att E ICU-Non-ICU Team Checkup Tool.docx Form and Instruction
6 Attachment E: ICU/Non-ICU Team Checkup Tool Att E ICU-Non-ICU Team Checkup Tool.docx Form and Instruction
7 Attachment F: Surgical Services Team Checkup Tool Att F Surgical Services Team Checkup Tool.docx Form and Instruction
7 Attachment F: Surgical Services Team Checkup Tool Att F Surgical Services Team Checkup Tool.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Team Checkup Tool	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	6	Attachment E: ICU/Non-ICU Team Checkup Tool	Att E ICU-Non-ICU Team Checkup Tool.docx		Yes	Yes	Fillable Fileable
Form and Instruction	7	Attachment F: Surgical Services Team Checkup Tool	Att F Surgical Services Team Checkup Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 367	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	6,606	6,606
Annual IC Time Burden (Hours)	1,123	1,123
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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