Request for Approval

File Name: 2015002-XXX_Suicide_VA

Request for Approval Under the Generic Clearance for

Emergency Epidemic Investigation Data Collections
(0920-1011)

Instruction: This form should be completed by the primary contact person from the CDC CIO that will be sponsoring the investigation.

Determine if your investigation is appropriate for this Generic mechanism: Instruction: Before completing and submitting this form, determine first if the proposed investigation is appropriate for the EEI Generic ICR mechanism. Complete the checklist below. If you select “yes” to all criteria in Column A, the EEI Generic IR mechanism can be used. If you select “yes” to any criterion in Column B, the EEI Generic ICR mechanism cannot be used.

Column A	Column B
CDC epidemiological assistance is requested by one or more external partners (e.g., local, state, tribal, military, port, other federal agency, or international health authority or other partner organization). Yes No	The Investigation is initiated by CDC, without request from an external partner. Yes No
The investigation is urgent in nature (i.e., timely data are needed to inform rapid public health action to prevent or reduce injury, disease, or death). Yes No	The investigation is not urgent in nature. Yes No
The investigation is characterized by undetermined agent, undetermined source, undetermined mode of transmission, or undetermined risk factors. Yes No	The investigation is conducted for the primary purpose of program evaluation, surveillance, needs assessment, or research to contribute to generalizable knowledge. Yes No
One or more CDC staff (including trainees and fellows) will be deployed to the field. Yes No	CDC staff (including trainees or fellows) are not deployed to the field. Yes No
Data collection will be completed in 90 days or less. Yes No	Data collection expected to require greater than 90 days. Yes No

Did you select “Yes” to all criteria in Column A?

If yes, the EEI Generic ICR may be appropriate for your investigation. → You may proceed with this form.

Did you select “Yes” to any criterion in Column B?

If yes, the EEI Generic ICR is not appropriate for your investigation. → Stop completing this form now.

GenIC #

2015002

-

XXX

Date

11/4/2014

Title of Investigation: Instruction: Provide the title of the investigation in the following format: [Undetermined agent, undetermined source, undetermined mode of transmission, undetermined risk factor] for [disease/problem] among [subpopulation]—[State], [Year]

Undetermined risk factors for suicide among youth ages 10–24 years — Fairfax County, VA, 2014

Location of Investigation: Instruction: Indicate location where investigation will occur. If multiple locations, specify each one.

State:	Virginia
City/County (if applicable)	Fairfax County
Country	USA

Requesting Agency: Instruction: Indicate name of agency requesting epidemiological assistance and the name and position title of the requestor

Agency:	Virginia Department of Health
Name and Position Title:	Dr. David Trump, Chief Deputy Commissioner, Virginia Department of Health

Note: Attach the Letter of Invitation requesting support. The letter should include the following information: 1) background on the outbreak or event; 2) steps already taken toward prevention and control, if any; 3) request for CDC assistance, including objectives of the investigation; and 4) how data will be used to inform prevention and control measures. Sensitive information in the Letter of Invitation not appropriate for public dissemination should be redacted.

Description of Investigation

1. Problem to be Investigated: Instruction: Provide a summary of the outbreak or event. The summary should include all the information you know at this time about the outbreak or event and the investigation that is planned. At a minimum, please provide the following information: 1) background necessary to understand the importance of the outbreak or event, including a justification of the need for an investigation and why this issue requires an urgent response; 2) the objectives of the investigation, including how the information collected will be used to inform prevention and control measures; and 3) a brief overview of the investigation planned, including study design, respondents, mode of data collection. In the description, indicate whether a data collection instrument is attached with the GenIC request (refer to as Appendix 1, etc) and what instruments will be developed in the field. (suggested length: 250-500 words).

Since October 1, 2014, there have been 3 suicides among high school students in the Fairfax County Public School System in Fairfax County, Virginia. The recent deaths occurred in close physical proximity and time, which has promoted local public health officials, the public school system, community members, and parents to be concerned about a possible suicide cluster among youth in the community. This possible cluster occurs in the context of an increasing suicide rate among 10-24 year olds in Fairfax County from 18/100,000 in 2011 to 25/100,000 in 2013, and the community has already had 16 suicides among youth in 2014. There are indications that youth suicides may be primarily connected to one high school and two other high schools have had several suicides among its students in 2014. Although the community has previously dedicated extensive resources to suicide prevention activities, however the effectiveness has been limited given suicides continue to occur. The community has been unable to identify epidemiological factors contributing to the suicide risk or the unmet needs that must be addressed by preventive actions. Consequently, the Fairfax County Health Department and the Virginia Department of Health have requested CDC’s urgent assistance in investigating youth suicide and making recommendations for a public health response to prevent additional suicides among Fairfax County youth.

Epi-Aid objectives:

1. Assist the Commonwealth of Virginia Department of Health and the Fairfax County Department of Health in examining trends of fatal and non-fatal suicidal behaviors among youth from September 2010 through 2014 in Fairfax County, Virginia. This objective is the focus of the GenIC request as it will involve primary data collection by federal staff involving interviews with parents and focus groups with school counselors.

2. Identify epidemiologic information about fatal and non-fatal suicidal behaviors among youth in Fairfax County Virginia that can help inform prevention strategies implemented by the Commonwealth of Virginia Health Department, Fairfax County Department of Health, and their community partners. This objective is not part of the OMB request as it will involve analyzing existing data or involve contact with fewer than 10 individuals but it is provided for informational purposes. These data will include the Virginia Violent Death Reporting System, Fairfax County Youth Survey, Fairfax County School Climate Data, Virginia Department of Education school climate and violence data, Fairfax County EMS data, and Fairfax County syndromic surveillance data.

This GenIC seeks approval for primary data collection (Objective 1) to identify school and community level risk and protective factors that may be associated with youth suicide across the community. Interviews with school administrators and guidance counselors (Appendix 1) and focus groups with parents (Appendix 2) will be conducted. These data will be used to identify factors associated with youth suicide in Fairfax County and to inform public health prevention strategies.

2. Characteristics of Outbreak or Event (Check all that Apply):

Undetermined agent

Undetermined source

Undetermined mode of transmission

Undetermined risk factor

3. Respondents: Instruction: Select all that apply. For each respondent type selected, provide a brief description. Be sure to include a description of control respondents, if applicable. Use as much space as necessary for each description.

General public (describe):

Primary data collection from school administrators, guidance counselors, and parents from parent organizations (i.e., Parent Teacher Association) from schools that have been affected by youth suicide. Fairfax County Health Department will assist in identifying schools.

Healthcare staff (describe):

Laboratory staff (describe):

Patients (describe):

Restaurant staff (describe):

Other (describe):

4. Selection of Respondents: Instruction: Provide a brief description of how respondents will be identified and selected. Use as much space as necessary for the description.

Fairfax County Health Department will identify schools impacted by suicide in the past year. We anticipate approximately 9 schools will be identified. Within each school, Fairfax County Health Department will identify school administrators and guidance counselors. The Fairfax County Health Department will work with school administrators to identify parents (such as through parent organizations).

5. Study Design: Instruction: Select all that apply. For each study design planned, provide a brief description. Use as much space as necessary for the description.

Epidemiologic Study (indicate which type(s) below)

Descriptive Study (describe):

Interviews (Appendix 1) and focus groups (Appendix 2) will be used to identify school- and community-level risk and protective factors associated with youth suicide and suicide behaviors.

Cross-sectional Study (describe):

Cohort Study (describe):

Case-Control Study (describe):

Other (describe):

Environmental Assessment (describe):

Laboratory Testing (describe):

Other (describe):

6. Data Collection Mode: Instruction: Select all that apply. For each data collection mode planned, provide a brief description. Use as much space as necessary for the description.

Survey Mode (indicate which mode(s) below):

Face-to-face Interview (describe):

Interviews with school administrators and guidance counselors (Appendix 1)

Telephone Interview (describe):

Self-administered Paper-and-Pencil Questionnaire (describe):

Self-administered Internet Questionnaire (describe):

Other (describe):

Focus groups with parents (Appendix 2)

Medical Record Abstraction (describe):

Biological Specimen Sample

Environmental Sample:

Other (describe):

7. Type of Information to be Collected: Instruction: Select all that apply. For each type of information to be collected, provide a brief description. Use as much space as necessary for the description.

Behaviors (describe):

Clinical information/symptoms (describe):

Contact information (describe):

Demographic information (describe):

School administrators and guidance counselors’ role in school and time associated with school. Parent focus group participants’ organization they represent and how long they have lived in Fairfax County, Virginia.

Environmental factors (describe):

Exposures (describe):

Medical history (describe):

Risk factors (describe):

School administrators’, guidance counselors’, and parents’ identification of school and community factors that increase the risk for youth suicide (i.e., what issues in the school and community increase the risk of youth suicide)

Specimen/lab information (describe):

Travel history (describe):

Other (describe):

School administrators and guidance counselors:

• perceptions of their school’s community and what it is like for students, teachers, and staff

• perceptions of parents’ involvement in school

• challenges faced in their school

• assets of their school

• activities/policies previously implemented for suicide prevention in schools

School administrators, guidance counselors, and parents:

• accessibility of mental health care/resources

• perceptions of how suicide is a problem in their schools and local community

• perception of how the community, media, schools, parents, and young people respond when a young person dies by suicide

• perceptions of the role of social and traditional media in recent suicides

8. Duration of Data Collection (number of weeks):

2 weeks

Research Determination: Instruction: Indicate the research determination decision. If the decision is research, provide the research determination letter and IRB approval, if required.

Research

Not Research

CDC Investigation Lead: Instruction: Indicate the name, title, and affiliation of the person who will serve as the CDC lead for this investigation.

Name:	Erica Spies
Title:	EIS Officer
Affiliation:	NCIPC/DVP/REB

CDC Sponsoring Program and Primary Contact Person: Instruction: Indicate the sponsoring CIO/Division/Branch for this investigation. Indicate the name, title, and contact information of the CDC Primary Contact Person for this investigation. Indicate the preferred method of contact during the OMB approval process. Note, contact person or a designee must be available during the OMB approval process in case questions arise.

CIO/Division/Branch:	NCIPC/DVP/REB
Name:	Erica Spies
Title:	EIS Officer

Certification: Please read the certification carefully. Type your name to validate that you are providing certification. Note: If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Certification should be signed by the CDC Primary Contact Person for this Investigation.

I, [insert name of CDC sponsoring program contact], certify the following to be true:

1. The collection is voluntary.

2. Respondents will not be personally identified in any published reports of the study.

3. Information gathered will be primarily used to inform effective prevention and control measures.

CDC Sponsoring Program Primary Contact Name:	Erica Spies
Date of Certification:	11/4/2014

Requested Approval Date (mm/dd/yyyy): Instruction: Indicate the date by which approval is needed.

11/7/2014

E-mail the completed form to the Information Collection Request Liaison (ICRL) or EIS program ICRL designee.

EEI Information Collection Request Liaison:

Danice Eaton, PhD, MPH

EIS Program Staff Epidemiologist

EWB/DSEPD/CDC

2400 Century Center, MS E-92

Office: 404.498.6389
[email protected]

For internal use. Do not complete.

Date/Time initial GenIC received by ICRL		10/17/2014
Date/Time final GenIC received by ICRL		11/4/2014. 1:50PM
Date/Time submitted to OMB		11/4/14 2:30PM
Date/Time approved

Date Form Revised: GenIC 6.16.14 5