Data Collection for Hospitals

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

First you must answer question 1, is this an eligible NTSIP incident? Then there are 10 tabs to click on to get the
different sets of questions to fill in. Only the questions with numbers need to be asked, the others are
automatically filled in by the computer or are legacy HSEES questions that the state may choose to fill in if they
have the information. There are mostly drop down menus for ease of use.

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

Form Approved
OMB No. 0923-XXXX
Exp. Date xx/xx/20xx

Public reporting burden of this collection of information is estimated to average 30 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74,
Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)

Attachment E. NTSIP State Data Collection Form Screen Shots (Web version)
This last page is for the state to enter data that will help with analysis of the incident later on. They are not
questions they will ask of the public.