OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

Formative Research for Sepsis and Antibiotic Use Campaigns

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

Documents and Forms
Document Name
Document Type
Form
Other-Focus Group Guide
Other-Focus Group Guide
Other-Focus Group Guide
Other-Focus Group Guide
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Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
Form
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Form
Form
IC Document
IC Document
IC Document
IC Document
IC Document
IC Document
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IC Document
Information Collection (IC) Details

View Information Collection (IC)

Formative Research for Sepsis and Antibiotic Use Campaigns 17NZ
 
New
 
Voluntary
 

Document Type Form No. Form Name Instrument File URL 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

Health Illness Prevention

 

750 0
   
Individuals or Households
 
   100 %

  Approved Program Change Due to New Statute Program Change Due to Agency Discretion Change Due to Adjustment in Agency Estimate Change Due to Potential Violation of the PRA Previously Approved
Annual Number of Responses for this IC 750 0 750 0 0 0
Annual IC Time Burden (Hours) 208 0 208 0 0 0
Annual IC Cost Burden (Dollars) 0 0 0 0 0 0

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.