Document Name Document Type
Message and material testing for the Be Antibiotics Aware (BAA) campaign for healthcare providers (HCPs) Form and Instruction
Screening Form for Dentists SCREENER - Dentist_CLEARED_2019-10-01.docx Form and Instruction
Screening Form for Hospitalists SCREENER - Hospitalist_CLEARED_2019-10-01.docx Form and Instruction
Screening Form for Nurses in Nursing Homes SCREENER - Nurse_CLEARED_2019-10-01.docx Form and Instruction
Screening Form for Community Pharmacists SCREENER - Pharmacist_CLEARED_2019-10-01.docx Form and Instruction
Screening Form for Advanced Practice Providers and Physi SCREENER - Physician_CLEARED_2019-10-01.docx Form and Instruction
Interviewer Guide for Dentists GUIDE - Dentist_CLEARED_2019-10-02.docx Form and Instruction
Interviewer Guide for Hospitalists GUIDE - Hospitalist_CLEARED_2019-10-02.docx Form and Instruction
Interviewer Guide for Nurses in Nursing Homes GUIDE - Nurse_CLEARED_2019-10-02.docx Form and Instruction
Interviewer Guide for Community Pharmacists GUIDE - Pharmacist_CLEARED_2019-10-02.docx Form and Instruction
Interviewer Guide for Advanced Practice Providers and Ph GUIDE - Physician_CLEARED_2019-10-02.docx Form and Instruction
HMTS Expedited Review Form_AU HCPs_2019-09-26.pdf HMTS Project Template IC Document
HMTS Expedited Review Form_Attachment A_Study population (HCPs).docx HMTS Template Attachment A - Study Population IC Document
HMTS Expedited Review Form_Attachment B_Incentives (HCPs).docx HMTS Template Attachment B - Incentives IC Document
IRB Exempt Approval Documents 7-15-19.pdf IRB Exemption Determination IC Document
MATERIALS - Dentists - 7 Ways Dentists Can BAA.pdf Testing Item for Dentists (7 ways) IC Document
MATERIALS - Dentists - Checklist for Abx Rx.pdf Testing Item for Dentists (Checklist) IC Document
MATERIALS - Dentists - Do You Need Abx From Your Dentist.pdf Testing Item for Dentists (Abx) IC Document
MATERIALS - Hospitalists - 5 Ways Hospitalists Can BAA.pdf Testing Item for Hospitalists (5 Ways) IC Document
MATERIALS - Hospitalists - Abx Time Out at Discharge Flowsheet.pdf Testing Item for Hospitalists (Flowsheet) IC Document
MATERIALS - Hospitalists - Avoid Treatment of ASB Poster.pdf Testing Item for Hospitalists (Poster) IC Document
MATERIALS - Nurses - Avoid Treatment of ASB.pdf Testing Item for Nurses (Avoid Treatment) IC Document
MATERIALS - Nurses - Do You Need Antibiotics.pdf Testing Item for Nurses (Do you Need) IC Document
MATERIALS - Nurses - What's Got You Sick Chart.pdf Testing item for Nurses (Chart) IC Document
MATERIALS - Pharmacists - Relief for Colds and Cough.pdf Testing Item for Pharmacists (Cold and Cough) IC Document
MATERIALS - Pharmacists - Taking Your Abx.pdf Testing Item for Pharmacists (Taking your Abx) IC Document
MATERIALS - Pharmacists - Verify Penicillin Allergy.pdf Testing Item for Pharmacists (Penicillin Allergy) IC Document
MATERIALS - Physicians - 5 Ways NH HCPs Can BAA.pdf Testing Item for APP and Physicians (5 Ways) IC Document
MATERIALS - Physicians - Do You Need Antibiotics.pdf Testing Item for APP and Physicians (Do you Need) IC Document
MATERIALS - Physicians - Improve Comm Poster.pdf Testing Item for APP and Physicians (Communication) IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:	Message and material testing for the Be Antibiotics Aware (BAA) campaign for healthcare providers (HCPs)	Agency IC Tracking Number:	0920-19BSC

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 and Instruction	n/a	Screening Form for Dentists	SCREENER - Dentist_CLEARED_2019-10-01.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Screening Form for Hospitalists	SCREENER - Hospitalist_CLEARED_2019-10-01.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Screening Form for Nurses in Nursing Homes	SCREENER - Nurse_CLEARED_2019-10-01.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Screening Form for Community Pharmacists	SCREENER - Pharmacist_CLEARED_2019-10-01.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Screening Form for Advanced Practice Providers and Physicians in Nursing Homes	SCREENER - Physician_CLEARED_2019-10-01.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interviewer Guide for Dentists	GUIDE - Dentist_CLEARED_2019-10-02.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interviewer Guide for Hospitalists	GUIDE - Hospitalist_CLEARED_2019-10-02.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interviewer Guide for Nurses in Nursing Homes	GUIDE - Nurse_CLEARED_2019-10-02.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interviewer Guide for Community Pharmacists	GUIDE - Pharmacist_CLEARED_2019-10-02.docx	Yes	Yes	Fillable Fileable
Form and Instruction	n/a	Interviewer Guide for Advanced Practice Providers and Physicians in Nursing Homes	GUIDE - Physician_CLEARED_2019-10-02.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: 225	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Businesses or other for-profits, Not-for-profit institutions

Percentage of Respondents Reporting Electronically: 100 %

	Approved	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	225	225
Annual IC Time Burden (Hours)	64	64
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
HMTS Project Template	HMTS Expedited Review Form_AU HCPs_2019-09-26.pdf	10/02/2019
HMTS Template Attachment A - Study Population	HMTS Expedited Review Form_Attachment A_Study population (HCPs).docx	10/02/2019
HMTS Template Attachment B - Incentives	HMTS Expedited Review Form_Attachment B_Incentives (HCPs).docx	10/02/2019
IRB Exemption Determination	IRB Exempt Approval Documents 7-15-19.pdf	10/02/2019
Testing Item for Dentists (7 ways)	MATERIALS - Dentists - 7 Ways Dentists Can BAA.pdf	10/02/2019
Testing Item for Dentists (Checklist)	MATERIALS - Dentists - Checklist for Abx Rx.pdf	10/02/2019
Testing Item for Dentists (Abx)	MATERIALS - Dentists - Do You Need Abx From Your Dentist.pdf	10/02/2019
Testing Item for Hospitalists (5 Ways)	MATERIALS - Hospitalists - 5 Ways Hospitalists Can BAA.pdf	10/02/2019
Testing Item for Hospitalists (Flowsheet)	MATERIALS - Hospitalists - Abx Time Out at Discharge Flowsheet.pdf	10/02/2019
Testing Item for Hospitalists (Poster)	MATERIALS - Hospitalists - Avoid Treatment of ASB Poster.pdf	10/02/2019
Testing Item for Nurses (Avoid Treatment)	MATERIALS - Nurses - Avoid Treatment of ASB.pdf	10/02/2019
Testing Item for Nurses (Do you Need)	MATERIALS - Nurses - Do You Need Antibiotics.pdf	10/02/2019
Testing item for Nurses (Chart)	MATERIALS - Nurses - What's Got You Sick Chart.pdf	10/02/2019
Testing Item for Pharmacists (Cold and Cough)	MATERIALS - Pharmacists - Relief for Colds and Cough.pdf	10/02/2019
Testing Item for Pharmacists (Taking your Abx)	MATERIALS - Pharmacists - Taking Your Abx.pdf	10/02/2019
Testing Item for Pharmacists (Penicillin Allergy)	MATERIALS - Pharmacists - Verify Penicillin Allergy.pdf	10/02/2019
Testing Item for APP and Physicians (5 Ways)	MATERIALS - Physicians - 5 Ways NH HCPs Can BAA.pdf	10/02/2019
Testing Item for APP and Physicians (Do you Need)	MATERIALS - Physicians - Do You Need Antibiotics.pdf	10/02/2019
Testing Item for APP and Physicians (Communication)	MATERIALS - Physicians - Improve Comm Poster.pdf	10/02/2019

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

Message and material testing for the Be Antibiotics Aware (BAA) campaign for healthcare providers (HCPs)

CDC and ATSDR Health Message Testing System

OMB: 0920-0572

IC ID: 237853

View Information Collection (IC)