Information Collection

Structural Assessments

IC 258913 under ICR 202407-0935-001 · OMB 0935-0265.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 1 Structural Assessments	Form and Instruction
Form 1 Structural Assessment-Improving Antibiotic Use Cohort-Brick and Mortar Practices Structural Assessments	Form and Instruction
Form 2 Structural Assessment - Improving Antibiotic Use Cohort - Telemedicine-Only Organizations Structural Assessments	Form and Instruction
1 Structural Assessment-Improving Antibiotic Use Cohort-Br Attachment A Structural Assessment - Antibiotic Use Cohort_Brick and Mortar (updated).docx	Form and Instruction
1 Structural Assessment-Improving Antibiotic Use Cohort-Br Attachment A Structural Assessment - Antibiotic Use Cohort_Brick and Mortar (updated).docx	Form and Instruction
2 Structural Assessment - Improving Antibiotic Use Cohort Attachment B Structural Assessment - Antibiotic Use Cohort_Telemedicine Only (updated).docx	Form and Instruction
2 Structural Assessment - Improving Antibiotic Use Cohort Attachment B Structural Assessment - Antibiotic Use Cohort_Telemedicine Only (updated).docx	Form and Instruction
Att A_Structural Assessment_Cancer Diagnostic Process Cohort 1.26.2023.docx Structural Assessment_Cancer Diagnostic Process Cohort	IC Document
Att A_Structural Assessment_Cancer Diagnostic Process Cohort 1.26.2023.docx Structural Assessment_Cancer Diagnostic Process Cohort	IC Document
Att B_Structural Assessment_Antibiotic Stewardship Cohort.docx Structural Assessment_Antibiotic Stewardship Cohort	IC Document
Att B_Structural Assessment_Antibiotic Stewardship Cohort.docx Structural Assessment_Antibiotic Stewardship Cohort	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

Structural Assessments

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

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	1				Yes	Yes	Fillable Fileable
Form and Instruction	2				Yes	Yes	Fillable Fileable

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Health Care Services

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 188

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	Previously Approved
Annual Number of Responses for this IC	376	-24	400
Annual IC Time Burden (Hours)	75	-5	80
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Structural Assessment_Cancer Diagnostic Process Cohort		03/06/2023
Structural Assessment_Antibiotic Stewardship Cohort		03/06/2023

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

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