TEAM CHECK-UP TOOL – Long-Term Care (LTC)

The AHRQ Safety Program for Methicillin-Resistant Staphylococcus aureus (MRSA) Prevention

Documents and Forms

Document Name Document Type
Form 8 TEAM CHECK-UP TOOL – Long-Term Care (LTC) Form and Instruction
8 Attachment G: LTC Team Checkup Tool Att G LTC Team Checkup Tool.docx Form and Instruction
8 Attachment G: LTC Team Checkup Tool Att G LTC Team Checkup Tool.docx Form and Instruction

Information Collection (IC) Details

IC Title:	TEAM CHECK-UP TOOL – Long-Term Care (LTC)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Unchanged

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	8	Attachment G: LTC Team Checkup Tool	Att G LTC Team Checkup Tool.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 100	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: 100 %

	Approved	Previously Approved
Annual Number of Responses for this IC	1,800	1,800
Annual IC Time Burden (Hours)	306	306
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.