[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities

[OS] CDC/ATSDR Formative Research and Tool Development

Documents and Forms

Document Name Document Type
[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities Form and Instruction
DHQP Interview Screener Attachment 1_DHQP_Screener_4.16.25.docx Form and Instruction
Interview Guide: Resident and Family/Close Friend (Paire Attachment 4_DHQP_Resident and Family Guide_3.25.25_Final.docx Form and Instruction
Interview Guide: Family/Close Friend (Follow-Up Intervie Attachment 5_DHQP_Family Follow-Up Guide_4.16.25.docx Form and Instruction
Attachment 2_DHQP_Consent Form_Resident_4.16.25.docx Consent Form Resident IC Document
Attachment 3_DHQP_Consent Form_Family or Friend_4.16.25.docx Consent Form Family or Friend IC Document
Attachment 6_Human Subjects Determination Memo.pdf Research Determination IC Document
DHQP_Gen IC Request Form_4.16.25.docx GenIC Request Template IC Document
DHQP_OMB Supporting Statement A_4.16.25.docx SSA IC Document
DHQP_OMB Supporting Statement B_4.16.25.docx SSB IC Document

Information Collection (IC) Details

IC Title:	[NCEZID] In-Depth Interviews about Infection Prevention and Control Practices in Long-Term Care Facilities	Agency IC Tracking Number:	0920-25-0100

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	DHQP Interview Screener	Attachment 1_DHQP_Screener_4.16.25.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interview Guide: Resident and Family/Close Friend (Paired Interview)	Attachment 4_DHQP_Resident and Family Guide_3.25.25_Final.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interview Guide: Family/Close Friend (Follow-Up Interview)	Attachment 5_DHQP_Family Follow-Up Guide_4.16.25.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 234	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 90 %

	Requested	Previously Approved
Annual Number of Responses for this IC	234	234
Annual IC Time Burden (Hours)	63	63
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Consent Form Resident	Attachment 2_DHQP_Consent Form_Resident_4.16.25.docx	05/20/2025
Consent Form Family or Friend	Attachment 3_DHQP_Consent Form_Family or Friend_4.16.25.docx	05/20/2025
Research Determination	Attachment 6_Human Subjects Determination Memo.pdf	05/21/2025
GenIC Request Template	DHQP_Gen IC Request Form_4.16.25.docx	05/21/2025
SSA	DHQP_OMB Supporting Statement A_4.16.25.docx	05/21/2025
SSB	DHQP_OMB Supporting Statement B_4.16.25.docx	05/21/2025

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