Information Collection

Sepsis Campaign Development: Round 2 Concept/Materials Testing for Healthcare Providers

IC 227053 under ICR 201502-0920-001 · OMB 0920-0572.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Screenshots of the Sepsis Survey for Healthcare Professionals Sepsis Campaign Development: Round 2 Concept/Materials Testing for Healthcare Providers	Form
Screenshots of the Sepsis Survey for Healthcare Professi A.R2 Sepsis HCP Survey Screenshots.pdf	Form
Sepsis R2 Project Description_5.31.2017 - HCP.docx Project Description for Sepsis R2 Testing with HCP	IC Document
Sepsis_R2 Incentive Justification_5.31.2017- HCP.docx Justification for the Proposed Incentive	IC Document
C1.Visual with slogan_A.png Test Item C1. Visual with Slogan_A	IC Document
C2.Visual with slogan_B.png Test Item C2. Visual with Slogan_B	IC Document
C3.Visual with slogan_C.png Test Item C3. Visual with Slogan_C	IC Document
C4.Visual with slogan_D.png Test Item C4. Visual with Slogan_D	IC Document
C5.Visual with slogan_E.png Test Item C5. Visual with Slogan_E	IC Document
C6.Sepsis_Print_Concept_A.pdf Test Item C6. Print Concept_A	IC Document
C7.Sepsis_Print_Concept_B.pdf Test Item C7. Print Concept_B	IC Document
C8.Sepsis_Print_Concept_C.pdf Test Item C8. Print Concept_C	IC Document
C9.Sepsis Campaign Stimulus_TV Ads.docx Test Item C9. Campaign Stimulus_TV Ads	IC Document
C10.HCP Sepsis flier for R2 testing_FINAL.docx Test Item C10. Sepsis Flier for R2 Testing	IC Document
Sepsis R2_HMTSExpeditedReviewForm_v4 - HCP.pdf HMTS Form - Sepsus R2 Testing with HCP	IC Document

IC Title:

Sepsis Campaign Development: Round 2 Concept/Materials Testing for Healthcare Providers

Agency IC Tracking Number:

0920-17AGZ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	n/a				Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 462

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 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	462	462
Annual IC Time Burden (Hours)	56	56
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Project Description for Sepsis R2 Testing with HCP		06/05/2017
Justification for the Proposed Incentive		06/05/2017
Test Item C1. Visual with Slogan_A		06/05/2017
Test Item C2. Visual with Slogan_B		06/05/2017
Test Item C3. Visual with Slogan_C		06/05/2017
Test Item C4. Visual with Slogan_D		06/05/2017
Test Item C5. Visual with Slogan_E		06/05/2017
Test Item C6. Print Concept_A		06/05/2017
Test Item C7. Print Concept_B		06/05/2017
Test Item C8. Print Concept_C		06/05/2017
Test Item C9. Campaign Stimulus_TV Ads		06/05/2017
Test Item C10. Sepsis Flier for R2 Testing		06/05/2017
HMTS Form - Sepsus R2 Testing with HCP		06/05/2017

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

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