Form 2 Attachment B – Passive TA Collection Protocol

Attachment B

Passive Technical Assistance Protocol

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/XXXX

This document will be used to collect information from nursing homes when they contact TMF Health Quality Institute for technical assistance (TA). These items will be in an excel database to collect the information during a call.

Hello, this is [name] from TMF Health Quality Institute. How may I help you?

1. What tool are you using? [if necessary confirm the name of the tool from the Guide]

2. [If necessary] What kind of problem are you experiencing?

3. [Provide TA. Describe what was stated and issues.]

4. Was the issue resolved during the call?

5. Any follow-up needed? By whom?

6. [How long was the call (in minutes)?]

7. [Name of TA provider]

8. [Name of Nursing Home]

9. [Name of person calling from nursing home and contact information (email, phone, etc)]

Public reporting burden for this collection of information is estimated to average 20 minutes per response, the estimated time required to complete the interview. An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to: AHRQ Reports Clearance Officer Attention: PRA, Paperwork Reduction Project (0935-XXXX) AHRQ, 540 Gaither Road, Room #5036, Rockville, MD 20850.

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