Structural Assessments

The AHRQ Safety Program for Telemedicine: Improving Antibiotic Use

Documents and Forms

Document Name Document Type
Form 1 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

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:

Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form and Instruction	1	Structural Assessment-Improving Antibiotic Use Cohort-Brick and Mortar Practices	Attachment A Structural Assessment - Antibiotic Use Cohort_Brick and Mortar (updated).docx		Yes	Yes	Fillable Fileable
Form and Instruction	2	Structural Assessment - Improving Antibiotic Use Cohort - Telemedicine-Only Organizations	Attachment B Structural Assessment - 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: Not-for-profit institutions, Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 100 %

	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

Title	Document	Date Uploaded
Structural Assessment_Cancer Diagnostic Process Cohort	Att A_Structural Assessment_Cancer Diagnostic Process Cohort 1.26.2023.docx	03/06/2023
Structural Assessment_Antibiotic Stewardship Cohort	Att B_Structural Assessment_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.