Participant Experience Survey

The AHRQ Safety Program for Telemedicine: Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Form 4 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
5 Participant Experience Survey - Improving Antibiotic Use Attachment E Participant Experience Survey - Antibiotic Use Cohort_Telemedicine Only (updated).docx Form and Instruction

Information Collection (IC) Details

IC Title:	Participant Experience Survey	Agency IC Tracking Number:

Is this a Common Form? No		IC Status: Modified

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	4	Participant Experience Survey - Improving Antibiotic Use Cohort_Brick-and-Mortar Practices	Attachment D Participant Experience Survey - Antibiotic Use Cohort_Brick and Mortar (updated).docx		Yes	Yes	Fillable Fileable
Form and Instruction	5	Participant Experience Survey - Improving Antibiotic Use Cohort_Telemedicine-Only Organizations	Attachment E Participant Experience Survey - Antibiotic Use Cohort_Telemedicine Only (updated).docx		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 %

	Requested	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

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.