Form 1 Investigation Summary Forms

Form Approved

OMB No. 0920-0008

Exp. Date XX/XX/20010

Emergency Epidemic Investigation

EPI-AID No.: _______________

Title of the Investigation:

Used for the following purpose:

Date of the Investigation: Beginning: Ending:

Complete this section for each instrument used during the investigation:

Data Collection Method

□ Personal Interview □ Telephone

□ Mail □ Other (please specify)

1. Description of Respondents (i.e., individuals, households, physicians, state and local government, etc.)

2. Estimated Number of Respondents:

2. Number of Responses per Respondents (i.e., one time only, once a week for 2 weeks, 6 times, etc.):

2. Burden per Response (i.e., time taken for a respondent to complete the data collection instrument):

Total Annual Burden (Multiply BxCxD):

Project Officer:

Name:

Title:

CIO:

Phone:

Return completed form and blank questionnaire with trip report, MS D18.

Public reporting burden of this collection of information is estimated to average 15 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ATSDR Reports Clearance Officer; 1600 Clifton Road NE, MS E-11 Atlanta, Georgia 30333; ATTN: PRA (0920-0008)