TeamSTEPPS® Team Assessment Tool for Improving Diagnosis (Appendix B)

TeamSTEPPS® Stakeholder Surveys for AHRQ’s ACTION III Diagnostic Safety Capacity Building Contract Task 3

Documents and Forms

Document Name Document Type
Form 2 TeamSTEPPS® Team Assessment Tool for Improving Diagnosis (Appendix B) Form and Instruction
2 TeamSTEPPS® Team Assessment Tool for Improving Diagnosis Appendix B_Team Assessment Tool_1.4.22_.docx Form and Instruction
2 TeamSTEPPS® Team Assessment Tool for Improving Diagnosis Appendix B_Team Assessment Tool_1.4.22_.docx Form and Instruction

Information Collection (IC) Details

IC Title:	TeamSTEPPS® Team Assessment Tool for Improving Diagnosis (Appendix B)	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	2	TeamSTEPPS® Team Assessment Tool for Improving Diagnosis (Appendix B)	Appendix B_Team Assessment Tool_1.4.22_.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	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	350	350
Annual IC Time Burden (Hours)	88	88
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.