Information Collection

Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Consumers

IC 227267 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⚠️ Notice: This information collection may be referencing outdated material.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
Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Consumers	Form and Instruction
Screener for Consumers (Self-demanders and Self-expector Attach 2_Consumer Screener SD-SE FINAL 062117.doc	Form and Instruction
Screener for Consumers (Caregiver-demanders and Caregive Attach 3_Consumer Screener CD-CE FINAL 062117.doc	Form and Instruction
Pre-discussion Information Survey for Consumers (Self-de Attach 4_Consumer PDIS SE-SD FINAL 0062117.doc	Form and Instruction
Pre-discussion Information Survey for Consumers (Caregiv Attach 5_Consumer PDIS CE-CD FINAL 062117.doc	Form and Instruction
Online Focus Group Guide for Consumers Attach 6_Consumer Triad Guide_FINAL_062117.docx	Form and Instruction
Attach 1_AU R2 Consumer Project Desc_062117.docx Project Description	IC Document
HMTS Expedited Review Form - AU R2 Campaign - Consumers 062217.pdf HMTS Expedited Review form (AU R2/Consumers)	IC Document
Attach 7_Verbal Consent IDI-FG FINAL 062117.docx Verbal Consent	IC Document
Attach 8_Observer Confidentiality_FINAL 062117.doc Observer Confidentiality Agreement	IC Document
1.AU PSA Print Ad_Safe Play.pdf Test Item 1. Print Ad_Safe Play	IC Document
2.AU PSA Print Ad_Status Update.pdf Test Item 2. Print Ad_Status Update	IC Document
3.AU PSA Print Ad_The Right Tool.pdf Test Item 3. Print Ad_The Right Tool	IC Document
4.AU Campaign Stimulus_TV Ads.docx Test Item 4. Campaign Stimulus_TV Ads	IC Document
5.Visual with slogan_A.png Test Item 5. Visual with slogan_A	IC Document
6.Visual with slogan_B.png Test Item 6. Visual with slogan_B	IC Document
7.Visual with slogan_C.png Test Item 7. Visual with slogan_C	IC Document
8.Visual with slogan_D.jpg Test Item 8. Visual with slogan_D	IC Document
9.Visual with slogan_E.jpg Test Item 9. Visual with slogan_E	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Antibiotic Use Campaign: Round 2 (R2) Concept/Materials Testing with Consumers

Agency IC Tracking Number:

0920-17ATK

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	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	n/a	Pre-discussion Information Survey for Consumers (Self-demanders and Self-expectors)	Attach 4_Consumer PDIS SE-SD FINAL 0062117.doc	No		Paper Only
Form and Instruction	n/a	Pre-discussion Information Survey for Consumers (Caregiver-demanders and Caregiver-expectors)	Attach 5_Consumer PDIS CE-CD FINAL 062117.doc	No		Paper Only
Form and Instruction	n/a	Online Focus Group Guide for Consumers	Attach 6_Consumer Triad Guide_FINAL_062117.docx	Yes	No	Fillable Printable
Form and Instruction	n/a	Screener for Consumers (Self-demanders and Self-expectors)	Attach 2_Consumer Screener SD-SE FINAL 062117.doc	No		Paper Only
Form and Instruction	n/a	Screener for Consumers (Caregiver-demanders and Caregiver-expectors)	Attach 3_Consumer Screener CD-CE FINAL 062117.doc	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: 180

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 20 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	180	180
Annual IC Time Burden (Hours)	69	69
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Project Description	Attach 1_AU R2 Consumer Project Desc_062117.docx	06/22/2017
HMTS Expedited Review form (AU R2/Consumers)	HMTS Expedited Review Form - AU R2 Campaign - Consumers 062217.pdf	06/22/2017
Verbal Consent	Attach 7_Verbal Consent IDI-FG FINAL 062117.docx	06/22/2017
Observer Confidentiality Agreement	Attach 8_Observer Confidentiality_FINAL 062117.doc	06/22/2017
Test Item 1. Print Ad_Safe Play	1.AU PSA Print Ad_Safe Play.pdf	06/22/2017
Test Item 2. Print Ad_Status Update	2.AU PSA Print Ad_Status Update.pdf	06/22/2017
Test Item 3. Print Ad_The Right Tool	3.AU PSA Print Ad_The Right Tool.pdf	06/22/2017
Test Item 4. Campaign Stimulus_TV Ads	4.AU Campaign Stimulus_TV Ads.docx	06/22/2017
Test Item 5. Visual with slogan_A	5.Visual with slogan_A.png	06/22/2017
Test Item 6. Visual with slogan_B	6.Visual with slogan_B.png	06/22/2017
Test Item 7. Visual with slogan_C	7.Visual with slogan_C.png	06/22/2017
Test Item 8. Visual with slogan_D	8.Visual with slogan_D.jpg	06/22/2017
Test Item 9. Visual with slogan_E	9.Visual with slogan_E.jpg	06/22/2017

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