Form 1 Emergency Epidemic Investigations--Individuals, Househol

OMB No. 0920-0008

ATTACHMENT D

Emergency Epidemic Investigations

1. EPI AID No.:
2. Title of Investigation:
3. Used for the following purpose:
4. Date of Investigation:	Beginning:
	End:
Complete this section for each instrument used during the investigation
Data Collection Method	Personal Interview Telephone Mail Other (please specify):
A. Description of Respondents:
(i.e., individuals, households, physicians, etc.) B. Estimated Number of Respondents:
C. No. of responses per respondent (i.e., one time only, once a week for 2 weeks).
D. Burden per response (i.e. time to complete the data collection instrument)
Total Annual Burden (multiply B X C X D):
Project Officer:	Name:
	Title:
	CIO:
	Phone: