Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort

The AHRQ Safety Program for Telemedicine: Improving the Diagnostic Process and Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Form 11 Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort Form and Instruction
11 Attachment K: Antibiotic Prescription Data Template_Anti Att K_Antibiotic prescription data template_Antibiotic Stewardship Cohort.xlsx Form and Instruction
11 Attachment K: Antibiotic Prescription Data Template_Anti Att K_Antibiotic prescription data template_Antibiotic Stewardship Cohort.xlsx Form and Instruction
Att L_Instructions for Anitbiotic Prescription Data Template_Antibiotic Stewardship Cohort.docx Instructions for Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort IC Document
Att L_Instructions for Anitbiotic Prescription Data Template_Antibiotic Stewardship Cohort.docx Instructions for Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort IC Document

Information Collection (IC) Details

IC Title:	Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: New

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	11	Attachment K: Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Att K_Antibiotic prescription data template_Antibiotic Stewardship Cohort.xlsx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 150	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	2,700	2,700
Annual IC Time Burden (Hours)	2,700	2,700
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

Title	Document	Date Uploaded
Instructions for Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort	Att L_Instructions for Anitbiotic Prescription Data Template_Antibiotic Stewardship Cohort.docx	03/06/2023

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