Antibiotic Prescription Data Template_Antibiotic Use Cohort

The AHRQ Safety Program for Telemedicine: Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Attachment G Antibiotic Prescription Data Template- Antibiotic Use Cohort (updated).xlsx Other-database
Att L_Instructions for Anitbiotic Prescription Data Template_Antibiotic Stewardship Cohort.docx Instructions for Antibiotic Prescription Data Template_Antibiotic Stewardship Cohort IC Document

Information Collection (IC) Details

IC Title:	Antibiotic Prescription Data Template_Antibiotic Use Cohort	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
Other-database			Attachment G Antibiotic Prescription Data Template- Antibiotic Use Cohort (updated).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: 225	Number of Respondents for Small Entity: 0

Affected Public: Private Sector	Private Sector: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	Requested	Program Change Due to Agency Discretion	Previously Approved
Annual Number of Responses for this IC	4,050	1,350	2,700
Annual IC Time Burden (Hours)	4,050	1,350	2,700
Annual IC Cost Burden (Dollars)	0	0	0

Documents for IC

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.