Information Collection

Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Health Care Professionals

IC 227266 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⚠️ Notice: This information collection may be referencing outdated material.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

Document Name Document Type
Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Health Care Professionals Form and Instruction
Screener for Health Care Professionals Attach 2_HCP Screener FINAL 062117.doc Form and Instruction
Pre-Discussion Information Survey for Health Care Profes Attach 3_HCP PDIS FINAL 062117.doc Form and Instruction
In-Depth Interview Guide for Health Care Professionals Attach 4_HCP IDI Guide FINAL 062117.docx Form and Instruction
1.Conversation Starters_FINAL 04.21.17.docx Test Item 1. Conversation Starters IC Document
2.AU PSA Print Ad_Safe Play.pdf Test Item 2. Print Ad_Safe Play IC Document
3.AU PSA Print Ad_Status Update.pdf Test Item 3. Print Ad_Status Update IC Document
4.AU PSA Print Ad_The Right Tool.pdf Test Item 4. Print Ad_The Right Tool IC Document
5.AU Campaign Stimulus_TV Ads.docx Test Item 5. Campaign Stimulus_TV Ads IC Document
6.Visual with slogan_A.png Test Item 6. Visual with slogan_A IC Document
7.Visual with slogan_B.png Test Item 7. Visual with slogan_B IC Document
8.Visual with slogan_C.png Test Item 8. Visual with slogan_C IC Document
9.Visual with slogan_D.jpg Test Item 9. Visual with slogan_D IC Document
10.Visual with slogan_E.jpg Test Item 10. Visual with slogan_E IC Document
Attach 1_AU R2 HCP Project Desc and Burden_062117.docx Project Description IC Document
HMTS Expedited Review Form - AU R2 Campaign - HCPs 062017.pdf HMTS Expedited Review Form (AU R2/HCP) IC Document
Attach 5_Verbal Consent IDI-FG FINAL 062117.docx Verbal Consent IC Document
Attach 6_Observer Confidentiality_FINAL 062117.doc Observer Confidentiality Agreement IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Health Care Professionals	Agency IC Tracking Number:	0920-17ATJ

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Electronic Capability
Form and Instruction	n/a	Screener for Health Care Professionals	Attach 2_HCP Screener FINAL 062117.doc	No	Paper Only
Form and Instruction	n/a	Pre-Discussion Information Survey for Health Care Professionals	Attach 3_HCP PDIS FINAL 062117.doc	No	Paper Only
Form and Instruction	n/a	In-Depth Interview Guide for Health Care Professionals	Attach 4_HCP IDI Guide FINAL 062117.docx	No	Paper Only

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 120	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 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	120	120
Annual IC Time Burden (Hours)	34	34
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Test Item 1. Conversation Starters	1.Conversation Starters_FINAL 04.21.17.docx	06/21/2017
Test Item 2. Print Ad_Safe Play	2.AU PSA Print Ad_Safe Play.pdf	06/21/2017
Test Item 3. Print Ad_Status Update	3.AU PSA Print Ad_Status Update.pdf	06/21/2017
Test Item 4. Print Ad_The Right Tool	4.AU PSA Print Ad_The Right Tool.pdf	06/21/2017
Test Item 5. Campaign Stimulus_TV Ads	5.AU Campaign Stimulus_TV Ads.docx	06/21/2017
Test Item 6. Visual with slogan_A	6.Visual with slogan_A.png	06/21/2017
Test Item 7. Visual with slogan_B	7.Visual with slogan_B.png	06/21/2017
Test Item 8. Visual with slogan_C	8.Visual with slogan_C.png	06/21/2017
Test Item 9. Visual with slogan_D	9.Visual with slogan_D.jpg	06/21/2017
Test Item 10. Visual with slogan_E	10.Visual with slogan_E.jpg	06/21/2017
Project Description	Attach 1_AU R2 HCP Project Desc and Burden_062117.docx	06/22/2017
HMTS Expedited Review Form (AU R2/HCP)	HMTS Expedited Review Form - AU R2 Campaign - HCPs 062017.pdf	06/22/2017
Verbal Consent	Attach 5_Verbal Consent IDI-FG FINAL 062117.docx	06/22/2017
Observer Confidentiality Agreement	Attach 6_Observer Confidentiality_FINAL 062117.doc	06/22/2017

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