Information Collection

Team Antibiotic Review Form (Cohorts 1, 2, and 3)

IC 227702 under ICR 201707-0935-003 · OMB 0935-0238.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0238 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form D Team Antibiotic Review Form (Cohorts 1, 2, and 3)	Form and Instruction
D Attachment D: Team Antibiotic Review Form Att D Team Antibiotic Review Form.docx	Form and Instruction
E Attachment E: Completion Guide for Team Antibiotic Revie Att E Completion Guide for Team Antibiotic Review Form.docx	Form and Instruction

IC Title:

Team Antibiotic Review Form (Cohorts 1, 2, and 3)

Agency IC Tracking Number:

Is this a Common Form? No

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	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	D	Attachment D: Team Antibiotic Review Form	Att D Team Antibiotic Review Form.docx		No		Paper Only
Form and Instruction	E	Attachment E: Completion Guide for Team Antibiotic Review Form	Att E Completion Guide for Team Antibiotic Review Form.docx		No		Fillable Printable

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 337

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	30,330	30,330
Annual IC Time Burden (Hours)	7,583	7,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
No associated records found

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