Get Ahead of Sepsis for Healthcare Providers

CDC and ATSDR Health Message Testing System

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-0572 can be found here:

Documents and Forms

Document Name Document Type
Get Ahead of Sepsis for Healthcare Providers Form
Sepsis HCP - Mod Guide - EMS Personnel_FINAL_9.12.19.docx Other-Moderator Guide
Sepsis HCP - Mod Guide - Long term care medical technicians and sitters_FINAL_9.12.19.docx Other-Moderator Guide
Sepsis HCP - Mod Guide - Long term care nurses_FINAL_9.12.19.docx Other-Moderator Guide
Screener - EMS Personnel Sepsis HCP - Screener_EMS_FINAL_9.12.19.docx Form
Screener - LTC Med tech/sitter Sepsis HCP - Screener_Long term care med techs and sitters_FINAL_9.12.19.docx Form
Screener - LTC Nurses Sepsis HCP - Screener_Long term care nurses_FINAL_9.12.19.docx Form
HMTS Expedited Review Form_Attachment A_Study Population (HCPs).docx Study population IC Document
HMTS Expedited Review Form_Attachment B_Incentives (HCPs).docx Incentive justification IC Document
IRB - Exempt Approval Documents 6.19.19.pdf IRB Approval IC Document
Sepsis HCP - Informed Consent_FINAL_9.12.19.docx Consent IC Document
HMTS Expedited Review Form_Sepsis HCPs.pdf Request for Approval IC Document

Information Collection (IC) Details

IC Title:	Get Ahead of Sepsis for Healthcare Providers	Agency IC Tracking Number:	0920-0572-19BSD

IC Status: New

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	none	Screener - EMS Personnel	Sepsis HCP - Screener_EMS_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable
Form	none	Screener - LTC Med tech/sitter	Sepsis HCP - Screener_Long term care med techs and sitters_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable
Form	none	Screener - LTC Nurses	Sepsis HCP - Screener_Long term care nurses_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable
Other-Moderator Guide			Sepsis HCP - Mod Guide - Long term care medical technicians and sitters_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable
Other-Moderator Guide			Sepsis HCP - Mod Guide - Long term care nurses_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable
Other-Moderator Guide			Sepsis HCP - Mod Guide - EMS Personnel_FINAL_9.12.19.docx	Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 162	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	162	162
Annual IC Time Burden (Hours)	38	38
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Study population	HMTS Expedited Review Form_Attachment A_Study Population (HCPs).docx	09/24/2019
Incentive justification	HMTS Expedited Review Form_Attachment B_Incentives (HCPs).docx	09/24/2019
IRB Approval	IRB - Exempt Approval Documents 6.19.19.pdf	09/24/2019
Consent	Sepsis HCP - Informed Consent_FINAL_9.12.19.docx	09/24/2019
Request for Approval	HMTS Expedited Review Form_Sepsis HCPs.pdf	09/25/2019

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