Information Collection

Be Antibiotic Aware Campaign

IC 237741 under ICR 201806-0920-001 · 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⚠️ Notice: This information collection may be referencing outdated material.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
Att 1 - Mod Guide for Adults 65+.docx	Other-Focus group guide
Att 3 - Mod Guide for Nursing Home Caregivers.docx	Other-Focus group guide
Att 5 - Mod Guide for SS Women_EN.docx	Other-Focus group guide
Att 6 - Mod Guide for SS Women_SP.docx	Other-Focus group guide
Att 11 - Mod Guide for Urgent Care Adults.docx	Other-Focus group guide
Screener for adults Att 2 - Screener for Adults 65+.docx	Form and Instruction
Screener for Nursing Home Caregivers Att 4 - Screener for Nursing Home Caregivers.docx	Form and Instruction
Screener for SS women - English Att 7 - Screener for SS Women_EN.docx	Form and Instruction
Screener for SS Women - Spanish Att 8 - Screener for SS Women_SP.docx	Form and Instruction
Screener for Urgent Care adults Att 12 - Screener for Urgent Care Adults.docx	Form and Instruction
Att 9 - Informed Consent for SS Women_EN.docx Consent for SS women - English	IC Document
Att 10 - Informed Consent for SS Women_SP.docx Consent for SS women - Spanish	IC Document
Att 13 - Consumer Informed Consent.docx Consent for consumers	IC Document
Att 14 - Adults 65+ Abx Side Effects.pdf Brochure - Abx side effects - adults	IC Document
Att 15 - Adults 65+ AU Brochure.pdf Brochure - AU - adults	IC Document
Att 16 - Adults 65+ Viral Illnesses Rx Pad.pdf Brochure - Viral illnes Rx Pad - adults	IC Document
Att 17 - Adults 65+ What's Got You Sick.pdf Brochure - What's got you sick - adults	IC Document
Att 18 - Caregivers-Abx Side Effects.pdf Brochure - Abx side effects - caregivers	IC Document
Att 19 - Caregivers-AU NH Brochure.pdf Brochure - AU - caregivers	IC Document
Att 20 - Caregivers-Committment about Abx.pdf Brochure - Commitment about Abx - caregivers	IC Document
Att 21 - Caregivers-What's Got You Sick.pdf Brochure - What's got you sick - caregivers	IC Document
Att 22 - SS Women-AU Brochure.pdf Brochure - AU - SS women	IC Document
Att 23 - SS Women-Viral Illness Rx Pad.pdf Brochure - Viral illness Rx Pad - SS women	IC Document
Att 24 - SS Women-What's Got You Sick.png Brochure - What's got you sick - SS women	IC Document
Att 25 - Urgent Care-AU Brochure.pdf Brochure - AU - urgent care	IC Document
Att 26 - Urgent Care-What is AR Bacteria.pdf Brochure - What is AR bacteria - urgent care	IC Document
Att 27 - Urgent Care-Viral Illnesses Rx Pad.pdf Brochure - Viral illness Rx Pad - urgent care	IC Document
Att 28 - Urgent Care-What's Got You Sick.pdf Brochure - What's got you sick - urgent care	IC Document
HMTS Expedited Review Form - Attachment A.docx Attachment A	IC Document
HMTS Expedited Review Form - Attachment B.docx Attachment B	IC Document
HMTS Expedited Review Form - AU Consumer Audiences.pdf genIC Request Form	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Be Antibiotic Aware Campaign

Agency IC Tracking Number:

0920-0572-19BQR

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
Other-Focus group guide			Att 1 - Mod Guide for Adults 65+.docx	Yes	No	Paper Only
Form and Instruction	none	Screener for adults	Att 2 - Screener for Adults 65+.docx	Yes	Yes	Fillable Fileable
Other-Focus group guide			Att 3 - Mod Guide for Nursing Home Caregivers.docx	Yes	No	Paper Only
Form and Instruction	none	Screener for Nursing Home Caregivers	Att 4 - Screener for Nursing Home Caregivers.docx	Yes	Yes	Fillable Fileable
Other-Focus group guide			Att 5 - Mod Guide for SS Women_EN.docx	Yes	No	Paper Only
Other-Focus group guide			Att 6 - Mod Guide for SS Women_SP.docx	Yes	No	Paper Only
Form and Instruction	none	Screener for SS women - English	Att 7 - Screener for SS Women_EN.docx	Yes	Yes	Fillable Fileable
Form and Instruction	none	Screener for SS Women - Spanish	Att 8 - Screener for SS Women_SP.docx	Yes	Yes	Fillable Fileable
Other-Focus group guide			Att 11 - Mod Guide for Urgent Care Adults.docx	Yes	No	Paper Only
Form and Instruction	none	Screener for Urgent Care adults	Att 12 - Screener for Urgent Care Adults.docx	Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 464

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 86 %

table that charts list of burden
	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	464	464
Annual IC Time Burden (Hours)	129	129
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Consent for SS women - English	Att 9 - Informed Consent for SS Women_EN.docx	09/12/2019
Consent for SS women - Spanish	Att 10 - Informed Consent for SS Women_SP.docx	09/12/2019
Consent for consumers	Att 13 - Consumer Informed Consent.docx	09/12/2019
Brochure - Abx side effects - adults	Att 14 - Adults 65+ Abx Side Effects.pdf	09/12/2019
Brochure - AU - adults	Att 15 - Adults 65+ AU Brochure.pdf	09/12/2019
Brochure - Viral illnes Rx Pad - adults	Att 16 - Adults 65+ Viral Illnesses Rx Pad.pdf	09/12/2019
Brochure - What's got you sick - adults	Att 17 - Adults 65+ What's Got You Sick.pdf	09/12/2019
Brochure - Abx side effects - caregivers	Att 18 - Caregivers-Abx Side Effects.pdf	09/12/2019
Brochure - AU - caregivers	Att 19 - Caregivers-AU NH Brochure.pdf	09/12/2019
Brochure - Commitment about Abx - caregivers	Att 20 - Caregivers-Committment about Abx.pdf	09/12/2019
Brochure - What's got you sick - caregivers	Att 21 - Caregivers-What's Got You Sick.pdf	09/12/2019
Brochure - AU - SS women	Att 22 - SS Women-AU Brochure.pdf	09/12/2019
Brochure - Viral illness Rx Pad - SS women	Att 23 - SS Women-Viral Illness Rx Pad.pdf	09/12/2019
Brochure - What's got you sick - SS women	Att 24 - SS Women-What's Got You Sick.png	09/12/2019
Brochure - AU - urgent care	Att 25 - Urgent Care-AU Brochure.pdf	09/12/2019
Brochure - What is AR bacteria - urgent care	Att 26 - Urgent Care-What is AR Bacteria.pdf	09/12/2019
Brochure - Viral illness Rx Pad - urgent care	Att 27 - Urgent Care-Viral Illnesses Rx Pad.pdf	09/12/2019
Brochure - What's got you sick - urgent care	Att 28 - Urgent Care-What's Got You Sick.pdf	09/12/2019
Attachment A	HMTS Expedited Review Form - Attachment A.docx	09/12/2019
Attachment B	HMTS Expedited Review Form - Attachment B.docx	09/12/2019
genIC Request Form	HMTS Expedited Review Form - AU Consumer Audiences.pdf	09/12/2019

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