Information Collection

Dental Survey-Practices and Experiences with Antibotic Prescribing (Online version)

IC 235611 under ICR 201904-0920-003 · OMB unassigned.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 0920-XXXX Dental Survey-Practices and Experiences with Antibotic Prescribing (Online version)	Form
0920-XXXX Dental Survey_CDC Outpatient SHEPheRD Practice and Exper Att. 3- Dental Survey CDC Outpatient SHEPHERD_Practice and Experience_REDCapVersion.pdf	Form
Att. 7-SecondRecruitment email for Dental Survey.tfs4.ocx.docx Att 7_Inital Dental Provider Recruitment Email	IC Document
Att. 5-ConsentCoverLetter_Survey_Y3.doc Att 5_Consent Cover Letter	IC Document

IC Title:

Agency IC Tracking Number:

0920-18APX

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	0920-XXXX	Dental Survey_CDC Outpatient SHEPheRD Practice and Experiences with Antibotic Prescribing	Att. 3- Dental Survey CDC Outpatient SHEPHERD_Practice and Experience_REDCapVersion.pdf		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Public Health Monitoring

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 25

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 25 %

table that charts list of burden
	Requested	Program Change Due to Agency Discretion
Annual Number of Responses for this IC	25	25
Annual IC Time Burden (Hours)	13	13
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Att 7_Inital Dental Provider Recruitment Email	Att. 7-SecondRecruitment email for Dental Survey.tfs4.ocx.docx	04/05/2019
Att 5_Consent Cover Letter	Att. 5-ConsentCoverLetter_Survey_Y3.doc	04/05/2019

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