Information Collection

Formative Research for Sepsis and Antibiotic Use Campaigns

IC 225603 under ICR 201610-0920-009 · OMB 0920-1154.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1154 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Formative Research for Sepsis and Antibiotic Use Campaigns	Form
Attachment 11_Consumer FG Guide Sepsis.docx	Other-Focus Group Guide
Attachment 12_HCP IDI Guide Sepsis.docx	Other-Focus Group Guide
Attachment 19_Consumer FG Moderator Guide AU.docx	Other-Focus Group Guide
Attachment 20_HCP IDI Guide AU.docx	Other-Focus Group Guide
Sepsis Consumer Screener - mothers Attachment 2_Consumer Screener 1_Mothers.doc	Form
Sepsis Consumer Screener - healthy adults 65+ Attachment 3_Consumer Screener 2_Healthy adults 65+.doc	Form
Sepsis Consumer Screener - AA men Attachment 4_Consumer Screener 3_AA men.doc	Form
HCP Sepsis Screener - ED triage nurse Attachment 5_HCP Screener 1_ED Triage Nurse.doc	Form
HCP Sepsis Screener - NP or PA Attachment 6_HCP Screener 2_NP or PA.doc	Form
HCP Sepsis Screener - PCP Attachment 7_HCP Screener 3_PCP.doc	Form
HCP Sepsis Screener - Gen med ward Attachment 8_HCP Screener 4_Gen Med Ward etc.doc	Form
Consumer Interview Sepsis Attachment 9_Consumer PDIS Sepsis.doc	Form
HCP Interview Sepsis Attachment 10_HCP PDIS Sepsis.doc	Form
HCP Antibiotic Use Screener Attachment 13_HCP Screener AU.doc	Form
Consumer Screener - SD-SE Attachment 14_Consumer Screener SD-SE.doc	Form
Consumer Screener - CD - CE Attachment 15_Consumer Screener CD-CE.doc	Form
HCP Antibiotic Use Interview Attachment 16_HCP PDIS AU.doc	Form
Consumer Interview - SE - SD Attachment 17_Consumer PDIS SE-SD.doc	Form
Consumer Interview - CE - CD Attachment 18_Consumer PDIS CE-CD.doc	Form
GenICRequestTemplate_2.7.docx Request for Approval	IC Document
SSA Sepsis and AU Formative Research_2.7.16.docx Supporting Statement A	IC Document
SSB Sepsis and AU Formative Research_1.27_CLEAN.docx Supporting Statement B	IC Document
Attachment 21_Informed Consent IDI-FG AU.docx Antibiotic Use Consent	IC Document
Attachment 22_Observer Confidentiality AU.doc Antibiotic Use Confidentiality	IC Document
Attachment 23_ Informed Consent IDI-FG Sepsis.docx Sepsis Consent	IC Document
Attachment 24_Observer Confidentiality Sepsis.docx Sepsis Confidentiality	IC Document
Attachment 25a_AJT - Antibiotic Resistance and Sepsis Raise Dialouge Prompt Action_IRB ....pdf Antibiotic Use IRB Letter	IC Document
Attachment 25b_AJT - Sepsis and Antibiotic Use Campaigns_IRB Approval Form_1-26-17-sign....pdf Sepsis IRB Letter	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Formative Research for Sepsis and Antibiotic Use Campaigns

Agency IC Tracking Number:

17NZ

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	none	Sepsis Consumer Screener - mothers	Attachment 2_Consumer Screener 1_Mothers.doc	Yes	Yes	Fillable Fileable
Form	none	Sepsis Consumer Screener - healthy adults 65+	Attachment 3_Consumer Screener 2_Healthy adults 65+.doc	Yes	Yes	Fillable Fileable
Form	none	Sepsis Consumer Screener - AA men	Attachment 4_Consumer Screener 3_AA men.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Sepsis Screener - ED triage nurse	Attachment 5_HCP Screener 1_ED Triage Nurse.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Sepsis Screener - NP or PA	Attachment 6_HCP Screener 2_NP or PA.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Sepsis Screener - PCP	Attachment 7_HCP Screener 3_PCP.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Sepsis Screener - Gen med ward	Attachment 8_HCP Screener 4_Gen Med Ward etc.doc	Yes	Yes	Fillable Fileable
Form	none	Consumer Interview Sepsis	Attachment 9_Consumer PDIS Sepsis.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Interview Sepsis	Attachment 10_HCP PDIS Sepsis.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Antibiotic Use Screener	Attachment 13_HCP Screener AU.doc	Yes	Yes	Fillable Fileable
Form	none	Consumer Screener - SD-SE	Attachment 14_Consumer Screener SD-SE.doc	Yes	Yes	Fillable Fileable
Form	none	Consumer Screener - CD - CE	Attachment 15_Consumer Screener CD-CE.doc	Yes	Yes	Fillable Fileable
Form	none	HCP Antibiotic Use Interview	Attachment 16_HCP PDIS AU.doc	Yes	Yes	Fillable Fileable
Form	none	Consumer Interview - SE - SD	Attachment 17_Consumer PDIS SE-SD.doc	Yes	Yes	Fillable Fileable
Form	none	Consumer Interview - CE - CD	Attachment 18_Consumer PDIS CE-CD.doc	Yes	Yes	Fillable Fileable
Other-Focus Group Guide			Attachment 11_Consumer FG Guide Sepsis.docx	Yes	No	Paper Only
Other-Focus Group Guide			Attachment 12_HCP IDI Guide Sepsis.docx	Yes	No	Paper Only
Other-Focus Group Guide			Attachment 19_Consumer FG Moderator Guide AU.docx	Yes	No	Paper Only
Other-Focus Group Guide			Attachment 20_HCP IDI Guide AU.docx	Yes	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: 750

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

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	750	750
Annual IC Time Burden (Hours)	208	208
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Request for Approval	GenICRequestTemplate_2.7.docx	02/07/2017
Supporting Statement A	SSA Sepsis and AU Formative Research_2.7.16.docx	02/07/2017
Supporting Statement B	SSB Sepsis and AU Formative Research_1.27_CLEAN.docx	02/07/2017
Antibiotic Use Consent	Attachment 21_Informed Consent IDI-FG AU.docx	02/07/2017
Antibiotic Use Confidentiality	Attachment 22_Observer Confidentiality AU.doc	02/07/2017
Sepsis Consent	Attachment 23_ Informed Consent IDI-FG Sepsis.docx	02/07/2017
Sepsis Confidentiality	Attachment 24_Observer Confidentiality Sepsis.docx	02/07/2017
Antibiotic Use IRB Letter	Attachment 25a_AJT - Antibiotic Resistance and Sepsis Raise Dialouge Prompt Action_IRB ....pdf	02/07/2017
Sepsis IRB Letter	Attachment 25b_AJT - Sepsis and Antibiotic Use Campaigns_IRB Approval Form_1-26-17-sign....pdf	02/07/2017

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