Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation

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

OMB: 0935-0179

IC ID: 244358

Documents and Forms
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Information Collection (IC) Details

View Information Collection (IC)

Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation
 
Unchanged
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL Available Electronically? Can Be Submitted Electronically? Electronic Capability
Form and Instruction 1 Appendix A: Setting Demographics Survey Appendix A_final cg 11 12 20.docx No   Paper Only
Form 2 Appendix B: Individual Respondent Characteristics (Providers) Appendix B_final_v2 cg 11 12 20.docx No   Paper Only
Form and Instruction 3 Appendix C: Individual Respondent Characteristics (Staff) Appendix C_final_v2 cg 11 12 20.docx No   Paper Only
Form and Instruction 4 Appendix D: Individual Respondent Characteristics (Admin) Appendix D_final_v2 cg 11 12 20.docx No   Paper Only
Form and Instruction 5 Appendix E: Organizational Readiness for Implementation Change (ORIC) Appendix E.docx No   Paper Only
Form and Instruction 6 Appendix F: Pilot Test Interview Protocol for Providers – TeamSTEPPS® Appendix F.docx No   Paper Only
Form and Instruction 7 Appendix G: Pilot Test Interview Protocol for Providers – No TeamSTEPPS® Appendix F.docx No   Paper Only
Form and Instruction 8 Appendix H: Pilot Test Evaluation Protocol for Staff – TeamSTEPPS® Appendix H.docx No   Paper Only
Form and Instruction 9 Appendix I: Pilot Test Evaluation Protocol for Staff – No TeamSTEPPS® Appendix I.docx No   Paper Only
Form and Instruction 10 Appendix J: Pilot Test Evaluation Protocol for Administrators – TeamSTEPPS® Appendix J.docx No   Paper Only
Form and Instruction 11 Appendix K: Pilot Test Evaluation Protocol for Administrators – No TeamSTEPPS® Appendix K.docx No   Paper Only
Form and Instruction 12 Appendix L: Training Observation Tool Appendix L.docx No   Paper Only

Health Health Care Services

 

641 0
   
Individuals or Households
 
   0 %

  Requested Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 641 0 0 0 0 641
Annual IC Time Burden (Hours) 389 0 0 0 0 389
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

Title Document Date Uploaded
Cover Letter OMB Cover Letter.docx 11/04/2020
Supporting Statement Supporting Statement Part A.docx 11/04/2020
            Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.

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