Information Collection

Team Checkup Tool

IC 248492 under ICR 202107-0935-003 · OMB 0935-0260.

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.