Diagnostic Safety Supplement

The AHRQ Safety Program for Telemedicine: Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Form 5 Diagnostic Safety Supplement Form and Instruction
5 Attachment E: Diagnostic Safety Supplement Att E_Diagnostic Safety Supplement.docx Form and Instruction

Information Collection (IC) Details

IC Title:	Diagnostic Safety Supplement	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Removed

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	5	Attachment E: Diagnostic Safety Supplement	Att E_Diagnostic Safety Supplement.docx		Yes	Yes	Fillable Fileable

Line of Business: Health

Subfunction: Consumer Health and Safety

Privacy Act System of Records
Title:	FR Citation:

Number of Respondents: 350	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 %

	Change Due to Adjustment in Agency Estimate	Previously Approved
Annual Number of Responses for this IC	-700	700
Annual IC Time Burden (Hours)	-140	140
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.