non-Substantive Change Request to 0920-1033

Non-substantive Change Request

0920-1033 – Expires 4/30/15

2014 Emergency Response to Ebola in West Africa: Data Collection for Assisting Foreign and International Entities Conduct Public Health Activities

CDC is requesting a non-substantive change request to add 4 forms, one which was previously approved under the Epi-Aid Mechanism, 0920-1011 and expired 12/31/14: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO). There are three new forms: Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) – French, Healthcare Worker - Ebola Virus Disease Investigation Questionnaire – Liberia, and Healthcare Worker - Ebola Virus Disease Exposure Risk Report - Sierra Leone.

The purpose of these forms is to investigate cases of Ebola Virus Disease in health care workers to determine what facility-based risk factors may have led to their infection, to allow for corrective changes in health care facility infection prevention practices and to contribute to epidemiologic understanding of the Ebola epidemic in order to combat it more effectively. These forms were chosen by a consultative process between the national Ministry of Health and implementing partners, based on experience piloting earlier versions. CDC was involved as a consultant in its development. The addition of multiple forms with similar functions reflects the reality on the ground that some partners use different forms from others (but this does not increase total burden as a given respondent would fill out only one).

The total approved hours in this collection is 54,282. The burden will increase by 400 hours because of the addition of these forms for a total of 54,682 hours.

Type of Respondent	Form Name	No. of Respondents	No. of Responses per Respondent	Avg. Burden per Response (in Hours)	Total Burden Hours
Healthcare Workers or Proxy	Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO)	300	1	30/60	150
Healthcare Workers or Proxy	Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) - French	300	1	30/60	150
Healthcare Workers or Proxy	Healthcare Worker - Ebola Virus Disease Investigation Questionnaire - Liberia	100	1	30/60	50
Healthcare Workers or Proxy	Healthcare Worker - Ebola Virus Disease Exposure Risk Report - Sierra Leone	100	1	30/60	50
Total					400

Attachments:

A - Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO)

B - Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) – French

B1 - Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO) – English Translation

C - Healthcare Worker - Ebola Virus Disease Investigation Questionnaire – Liberia

D - Healthcare Worker - Ebola Virus Disease Exposure Risk Report - Sierra Leone