Antibiotic Stewardship in Hospitals Assessment

CDC/ATSDR Formative Research and Tool Development

⚠️ Notice: This information collection may be referencing outdated material.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

Documents and Forms

Document Name Document Type
Antibiotic Stewardship in Hospitals Assessment Form
Hospital Antibiotic Stewardship Core Element Assessment Attachment A. Hospital Antibiotic Stewardship Core Element Assessment 20170630.docx Form
Feedback Questionnaire Attachment B. Feedback Questionnaire 20170630.docx Form
Attachment D. IRB Determination Letter.pdf Non-research determination IC Document
Attachment C. Letter to Study Participants 20170630.docx Letter to Study Participants IC Document
Supporting Statement A_Hospital Antibiotic Stewardship 20170630.doc Supporting Statement A IC Document
Supporting Statement B_ Hospital Antibiotic Stewardship 20170630.docx Supporting Statement B IC Document
GenICRequest_Hospital Antibiotic Stewardship 20170630.docx Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Antibiotic Stewardship in Hospitals Assessment	Agency IC Tracking Number:	0920-1154-17AUS

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Hospital Antibiotic Stewardship Core Element Assessment	Attachment A. Hospital Antibiotic Stewardship Core Element Assessment 20170630.docx		Yes	Yes	Fillable Fileable
Form	none	Feedback Questionnaire	Attachment B. Feedback Questionnaire 20170630.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 80	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	80	80
Annual IC Time Burden (Hours)	70	70
Annual IC Cost Burden (Dollars)	9,000	9,000

Documents for IC

Title	Document	Date Uploaded
Non-research determination	Attachment D. IRB Determination Letter.pdf	07/10/2017
Letter to Study Participants	Attachment C. Letter to Study Participants 20170630.docx	07/10/2017
Supporting Statement A	Supporting Statement A_Hospital Antibiotic Stewardship 20170630.doc	07/10/2017
Supporting Statement B	Supporting Statement B_ Hospital Antibiotic Stewardship 20170630.docx	07/10/2017
Request for Approval	GenICRequest_Hospital Antibiotic Stewardship 20170630.docx	07/10/2017

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