Information Collection

Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort

IC 258926 under ICR 202303-0935-001 · OMB 0935-0265.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0935-0265 can be found here:

Documents and Forms

Documents and forms in this information collection
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

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:

table that charts list of 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 %

table that charts list of burden
	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

table that charts IC Documents
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.