Team Antibiotic Review Form (Cohorts 1, 2, and 3)

The AHRQ Safety Program for Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Form E Team Antibiotic Review Form (Cohorts 1, 2, and 3) Form and Instruction
D Attachment D: Team Antibiotic Review Form Attachment D Team Antibiotic Review Form.1.docx Form and Instruction
E Attachment E: Completion Guide for Team Antibiotic Revie Attachment E Completion Guide for Team Antibiotic Review Form.1.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Team Antibiotic Review Form (Cohorts 1, 2, and 3)	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

Obligation to Respond: Voluntary

CFR Citation:

Information Collection Instruments:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	E	Attachment E: Completion Guide for Team Antibiotic Review Form	Attachment E Completion Guide for Team Antibiotic Review Form.1.docx		No		Fillable Printable
Form and Instruction	D	Attachment D: Team Antibiotic Review Form	Attachment D Team Antibiotic Review Form.1.docx		No		Paper Only

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 337	Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

	Approved	Previously Approved
Annual Number of Responses for this IC	30,330	30,330
Annual IC Time Burden (Hours)	7,583	7,583
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
No associated records found

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