Information Collection

Participant Experience Survey

IC 258921 under ICR 202407-0935-001 · OMB 0935-0265.

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form 4 Participant Experience Survey	Form and Instruction
Form 4 Participant Experience Survey - Improving Antibiotic Use Cohort_Brick-and-Mortar Practices Participant Experience Survey	Form and Instruction
Form 5 Participant Experience Survey - Improving Antibiotic Use Cohort_Telemedicine-Only Organizations Participant Experience Survey	Form and Instruction
4 Participant Experience Survey - Improving Antibiotic Use Attachment D Participant Experience Survey - Antibiotic Use Cohort_Brick and Mortar (updated).docx	Form and Instruction
4 Participant Experience Survey - Improving Antibiotic Use Attachment D Participant Experience Survey - Antibiotic Use Cohort_Brick and Mortar (updated).docx	Form and Instruction
5 Participant Experience Survey - Improving Antibiotic Use Attachment E Participant Experience Survey - Antibiotic Use Cohort_Telemedicine Only (updated).docx	Form and Instruction
5 Participant Experience Survey - Improving Antibiotic Use Attachment E Participant Experience Survey - Antibiotic Use Cohort_Telemedicine Only (updated).docx	Form and Instruction

IC Title:

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	4				Yes	Yes	Fillable Fileable
Form and Instruction	5				Yes	Yes	Fillable Fileable

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	188	63	125
Annual IC Time Burden (Hours)	63	21	42
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

table that charts IC Documents
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.

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