Information Collection

Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation

IC 244358 under ICR 202310-0935-001 · OMB 0935-0179.

⚠️ Notice: This information collection may be referencing outdated material.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

2025-01-24 - No material or nonsubstantive change to a currently approved collection

Documents and Forms

Document Name Document Type
Form 1 Building Diagnostic Safety Capacity – TeamSTEPPS® Course Evaluation Form and Instruction
1 Appendix A: Setting Demographics Survey Appendix A_final cg 11 12 20.docx Form and Instruction
1 Appendix A: Setting Demographics Survey Appendix A_final cg 11 12 20.docx Form and Instruction
2 Appendix B: Individual Respondent Characteristics (Provi Appendix B_final_v2 cg 11 12 20.docx Form
2 Appendix B: Individual Respondent Characteristics (Provi Appendix B_final_v2 cg 11 12 20.docx Form
3 Appendix C: Individual Respondent Characteristics (Staff Appendix C_final_v2 cg 11 12 20.docx Form and Instruction
3 Appendix C: Individual Respondent Characteristics (Staff Appendix C_final_v2 cg 11 12 20.docx Form and Instruction
4 Appendix D: Individual Respondent Characteristics (Admin Appendix D_final_v2 cg 11 12 20.docx Form and Instruction
4 Appendix D: Individual Respondent Characteristics (Admin Appendix D_final_v2 cg 11 12 20.docx Form and Instruction
5 Appendix E: Organizational Readiness for Implementation Appendix E.docx Form and Instruction
5 Appendix E: Organizational Readiness for Implementation Appendix E.docx Form and Instruction
6 Appendix F: Pilot Test Interview Protocol for Providers Appendix F.docx Form and Instruction
6 Appendix F: Pilot Test Interview Protocol for Providers Appendix F.docx Form and Instruction
7 Appendix G: Pilot Test Interview Protocol for Providers Appendix F.docx Form and Instruction
7 Appendix G: Pilot Test Interview Protocol for Providers Appendix F.docx Form and Instruction
8 Appendix H: Pilot Test Evaluation Protocol for Staff – T Appendix H.docx Form and Instruction
8 Appendix H: Pilot Test Evaluation Protocol for Staff – T Appendix H.docx Form and Instruction
9 Appendix I: Pilot Test Evaluation Protocol for Staff – N Appendix I.docx Form and Instruction
9 Appendix I: Pilot Test Evaluation Protocol for Staff – N Appendix I.docx Form and Instruction
10 Appendix J: Pilot Test Evaluation Protocol for Administr Appendix J.docx Form and Instruction
10 Appendix J: Pilot Test Evaluation Protocol for Administr Appendix J.docx Form and Instruction
11 Appendix K: Pilot Test Evaluation Protocol for Administr Appendix K.docx Form and Instruction
11 Appendix K: Pilot Test Evaluation Protocol for Administr Appendix K.docx Form and Instruction
12 Appendix L: Training Observation Tool Appendix L.docx Form and Instruction
12 Appendix L: Training Observation Tool Appendix L.docx Form and Instruction
OMB Cover Letter.docx Cover Letter IC Document
OMB Cover Letter.docx Cover Letter IC Document
Supporting Statement Part A.docx Supporting Statement IC Document
Supporting Statement Part A.docx Supporting Statement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Building Diagnostic Safety Capacity â TeamSTEPPSÂ® Course Evaluation	Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available 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 â TeamSTEPPSÂ®	Appendix F.docx	No	Paper Only
Form and Instruction	7	Appendix G: Pilot Test Interview Protocol for Providers â No TeamSTEPPSÂ®	Appendix F.docx	No	Paper Only
Form and Instruction	8	Appendix H: Pilot Test Evaluation Protocol for Staff â TeamSTEPPSÂ®	Appendix H.docx	No	Paper Only
Form and Instruction	9	Appendix I: Pilot Test Evaluation Protocol for Staff â No TeamSTEPPSÂ®	Appendix I.docx	No	Paper Only
Form and Instruction	10	Appendix J: Pilot Test Evaluation Protocol for Administrators â TeamSTEPPSÂ®	Appendix J.docx	No	Paper Only
Form and Instruction	11	Appendix K: Pilot Test Evaluation Protocol for Administrators â No TeamSTEPPSÂ®	Appendix K.docx	No	Paper Only
Form and Instruction	12	Appendix L: Training Observation Tool	Appendix L.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 641	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	641	641
Annual IC Time Burden (Hours)	389	389
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

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.