Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum

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

OMB: 0935-0179

IC ID: 222551

Documents and Forms

Document Name Document Type
Form 2 Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum Form and Instruction
Appendix A - _Focus Group Screener Guide.docx Other-screener
Appendix A - _Focus Group Screener Guide.docx Other-screener
Appendix C - Focus Group Feedback Sheet.docx Other-Feedback
Appendix C - Focus Group Feedback Sheet.docx Other-Feedback
2 2. Appendix B – Moderator Guide Appendix B - Moderator's Guide.docx Form and Instruction
2 2. Appendix B – Moderator Guide Appendix B - Moderator's Guide.docx Form and Instruction
Appendix D - List of Module naaes to be used in Focus Groups.docx 4. Appendix D – List of Module Names to be Used in Focus Groups IC Document
Appendix D - List of Module naaes to be used in Focus Groups.docx 4. Appendix D – List of Module Names to be Used in Focus Groups IC Document
Module 2 - Instructor Guide.pdf Module 2 IC Document
Module 2 - Instructor Guide.pdf Module 2 IC Document
Module 3 - Instructor Guide.pdf Module 3 IC Document
Module 3 - Instructor Guide.pdf Module 3 IC Document
Module 4 - Instructor Guide.pdf Module 4 IC Document
Module 4 - Instructor Guide.pdf Module 4 IC Document
Module 5 - Instructor Guide.pdf Module 5 IC Document
Module 5 - Instructor Guide.pdf Module 5 IC Document
Module 6 - Instructor Guide.pdf Module 6 IC Document
Module 6 - Instructor Guide.pdf Module 6 IC Document
Module_8.pdf Module 8 IC Document
Module_8.pdf Module 8 IC Document
Module 10 - Instructor Guide.pdf Module 10 IC Document
Module 10 - Instructor Guide.pdf Module 10 IC Document
Module 11 - Instructor Guide.pdf Module 11 IC Document
Module 11 - Instructor Guide.pdf Module 11 IC Document
OMB Cover Letter.doc Cover Memo IC Document
OMB Cover Letter.doc Cover Memo IC Document
TS LTC Generic Clearance Submission Form SS Part A.doc Supporting Statement A IC Document
TS LTC Generic Clearance Submission Form SS Part A.doc Supporting Statement A IC Document
TS for LTC OMB Supporting Statement Part B 7-18-16.docx Supporting Statement B IC Document
TS for LTC OMB Supporting Statement Part B 7-18-16.docx Supporting Statement B IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Focus Groups on TeamSTEPPS® for Long-Term Care Curriculum	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	2	2. Appendix B – Moderator Guide	Appendix B - Moderator's Guide.docx	No	Paper Only
Other-screener			Appendix A - _Focus Group Screener Guide.docx	No	Paper Only
Other-Feedback			Appendix C - Focus Group Feedback Sheet.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: 72	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 0 %

	Requested	Previously Approved
Annual Number of Responses for this IC	72	72
Annual IC Time Burden (Hours)	108	108
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
4. Appendix D – List of Module Names to be Used in Focus Groups	Appendix D - List of Module naaes to be used in Focus Groups.docx	07/20/2016
Module 2	Module 2 - Instructor Guide.pdf	07/20/2016
Module 3	Module 3 - Instructor Guide.pdf	07/20/2016
Module 4	Module 4 - Instructor Guide.pdf	07/20/2016
Module 5	Module 5 - Instructor Guide.pdf	07/20/2016
Module 6	Module 6 - Instructor Guide.pdf	07/20/2016
Module 8	Module_8.pdf	07/20/2016
Module 10	Module 10 - Instructor Guide.pdf	07/20/2016
Module 11	Module 11 - Instructor Guide.pdf	07/20/2016
Cover Memo	OMB Cover Letter.doc	07/20/2016
Supporting Statement A	TS LTC Generic Clearance Submission Form SS Part A.doc	07/20/2016
Supporting Statement B	TS for LTC OMB Supporting Statement Part B 7-18-16.docx	07/20/2016

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.