Information Collection

Get Ahead of Sepsis for Healthcare Providers

IC 237852 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⚠️ Notice: This information collection may be referencing outdated material.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
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.