Burden memo - Y1Q3

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014009-XXX
2014-062
Texas Department of State Health Services

Undetermined agent and risk factors for chikungunya or dengue virus infections among
community service volunteers in the Dominican Republic, 2014
Purpose of Investigation: (Use Among volunteers and staff traveling to the Dominican Republic, the primary objectives
as much space as necessary) of this investigation were to:
· Determine the incidence of recently-acquired:
a) Chikungunya virus (CHIKV) infections and consequent clinically
apparent illness
b) Dengue virus (DENV) infections and consequent clinically apparent
illness
· Conduct surveys to determine risk factors for:
a) CHIKV infection
b) DENV infection
· Recommend prevention and control measures for:
a) CHIKV infection
b) DENV infections
Duration of Data Collection: 90 days
Date Began:
7/9/2014
Date Ended:
10/5/2014
Lead Investigator
Name:
Emily Jentes
CIO/Division/Branch:
NCEZID/DGMQ
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Chikungunya_Questionnaire
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Service volunteers/staff investigated for evidence of CHIKV or
DENV infection and illness. In addition, demographic,
geographic, and behavioral factors associated with infection were
investigated.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil The Chikungunya_questionnaire was completed by the participant as
Questionnaire (describe):
a self-administered data collection instrument.
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
106
Total No. Sampled/Eligible to Respond (B): 127
Response Rate (A/B):
83%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Blood Collection Consent

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
A single blood sample was collected from each participant for CHIKV
and DENV diagnostic testing as described above. All participants had
one serum specimen collected (3-4 cc) to detect evidence of recent or
past CHIKV and DENV infection. All samples were tested by RTPCR (dengue and chikungunya), IgM ELISA (dengue and
chikungunya) and IgG ELISA (chikungunya and dengue); all IgGpositive specimens were confirmed by plaque reduction neutralization
test (PRNT). Serum specimens were sent to the CDC Dengue Branch
in San Juan, Puerto Rico, where they were batched and tested.
Chikungunya PRNTs were performed at CDC Arboviral Diseases
Branch in Fort Collins, Colorado.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
A single blood specimen of approximately 3-4cc.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
102
Total No. Sampled/Eligible to Respond (B): 127
Response Rate (A/B):
80%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Chikungunya_Questionnaire General
106
1
Public
Chikungunya_ConsentGeneral
102
1
Parental Permission Form
Public

Burden per
Response in
Minutes (C)
20

Total Burden
in Hours
(A x B x C)/60*
36

5

9

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014011-XXX
2014-063
Ministry of Health & Social Work, Republic of Liberia

Undetermined Sources and Risk Factors for an Ebola Hemorrhagic Fever Outbreak—
Liberia, 2014
Purpose of Investigation: (Use The investigation followed a case series study design, where case report forms (see
as much space as necessary) Appendix 1) were collected for every patient meeting the suspect case definition criteria.
Forms were collected through interview of patients or family members if patients have
died or are infants, in either French or the local language. Relevant clinical data, including
the patient’s date of onset, date of death, hospitalization and funeral information, and
contacts that the patient had prior to developing illness all are collected, in an effort to
determine the risk factors that led to this patient’s infection. If diagnostic testing confirms
that this patient has EVD, a separate contact tracing form (see Appendix 2) is completed
to collect information of people who had direct unprotected contact with the patient while
they were ill and prior to treatment in a facility with barrier nursing. These contacts were
then followed daily for onset of fever and other EVD symptoms, and were investigated as
cases and treated under barrier nursing precautions if they develop illness.
Duration of Data Collection: 90 days
Date Began:
7/08/2014
Date Ended:
10/06/2014
Lead Investigator
Name:
Barbara Knust
CIO/Division/Branch:
NCEZID/DHCPP
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Ebola_Case Investigation Form
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
The investigation followed a case series study design, where case
report forms were collected for every patient meeting the suspect
case definition criteria.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
When possible, diagnostic testing was used to confirm Ebola virus
infection or rule out infection. Laboratory testing was not performed
by CDC personnel, but laboratory results were recorded.
Other (describe):
Data Collection Mode (check all that apply)
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Hospital records were used to collect relevant clinical information in the
case report form
Biological Specimen Sample
Blood or oral swab specimens were collected from patients to confirm or
rule out Ebola virus infection. Laboratory testing were not be performed
by CDC personnel, but laboratory results were recorded.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
4000
Total No. Sampled/Eligible to Respond (B): 4000
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Ebola_Contract Tracing Form

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Contacts of confirmed Ebola case-patients were identified and
information about their location and type of contact was gathered.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
1500
Total No. Sampled/Eligible to Respond (B): 1500
Response Rate (A/B):
100%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Ebola_Case Investigation
General
4000
1
Form
Public
Ebola_Contract Tracing
General
1500
1
Form
Public

Burden per
Response in
Minutes (C)
25

Total Burden
in Hours
(A x B x C)/60*
1667

3

75

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014011-XX
2014-063
Ministry of Health & Social Work, Republic of Liberia

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

90 days
09/15/2014
10/03/2014

KAPs on Ebola Infection Control among Public and Health Care Workers and Interviews
of County Health Directors —Liberia, 2014
Purpose of Investigation: (Use Knowledge, attitudes and practices surveys to identify knowledge gaps and specific
as much space as necessary) behaviors related to EVD that are barriers to control methods.

Jonathan Yoder
NCEZID/DFWED

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
KAP Healthcare Worker Survey
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Knowledge, attitudes and practices surveys to identify knowledge
gaps and specific behaviors related to EVD that are barriers to
control methods.
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Interview healthcare workers at risk for Ebola exposure
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
40
Total No. Sampled/Eligible to Respond (B): 40
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

KAP General Public Survey

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Knowledge, attitudes and practices surveys to identify knowledge
gaps and specific behaviors related to EVD that are barriers to
control methods.
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Interview general public at risk for Ebola exposure
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
360
Total No. Sampled/Eligible to Respond (B): 360
Response Rate (A/B):
100%
Data Collection Instrument 3
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

KAP County Director Survey

Healthcare staff
County Directors

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Knowledge, attitudes and practices surveys to identify knowledge
gaps and specific behaviors related to EVD that are barriers to
control methods.
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Interview county directors responsible for local Ebola response
plans.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
6
Total No. Sampled/Eligible to Respond (B): 6
Response Rate (A/B):
100%
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
KAP Healthcare Worker
Healthcare
40
1
Survey
Worker
KAP General Public Survey General
360
1
Public
Page 3 of 4

Burden per
Response in
Minutes (C)
30

Total Burden
in Hours
(A x B x C)/60*
20

10

60

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
KAP County Director
Survey

County
Director

6

1

60

6

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 4 of 4

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):

2014013-XXX
2014-069

HHS/Administration for Children and Families (ACF)/Office of Refugee
Resettlement (ORR)

Title of Investigation:

Pneumonia cluster in Office of Refugee Resettlement/DOD Unaccompanied Alien
Children’s Shelters—Oklahoma, 2014
Purpose of Investigation: (Use Determine the scope of the outbreak, identify any potential sources of infection early
as much space as necessary) during the processing of these children, identify predisposing factors and other risk factors
for these respiratory illnesses, determine the primary agent of the outbreak, identify
contacts of ill children, assist with establishing better surveillance in the facility, and
implement appropriate measures to control and limit respiratory illnesses in this
vulnerable population.
Duration of Data Collection: 7 days
Date Began:
7/28/2014
Date Ended:
8/3/2014
Lead Investigator
Name:
Steve Waterman, MD, MPH
CIO/Division/Branch:
CDC/OID/NCEZID
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Respiratory Illness_Case Investigation Form
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Instrument was used to collect relevant information for influenzalike-illness (ILI) cases to better describe the outbreak and identify
potential risk factors and associations with illness.
Nasopharyngeal and Oropharyngeal swab samples from case
patients were collected when available.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Clinical medical record for ILI cases were reviewed
Biological Specimen Sample
Nasopharyngeal and Oropharyngeal swabs were requested for all ILI
cases still residing at the facility. Samples were tested using a multipathogen detection tool for the simultaneous detection of 21 respiratory
pathogens.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
23
Total No. Sampled/Eligible to Respond (B): 46
Response Rate (A/B):
50%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Hospitalized Case Investigation Form

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Instrument was used to collect relevant information for children
residing in shelters who were hospitalized with pneumonia to
better identify potential risk factors and associations with illness
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Medical records were obtained from the admitting hospital to complete
the instrument.
Biological Specimen Sample
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
3
Total No. Sampled/Eligible to Respond (B): 3
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Carriage Assent Form

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Unaccompanied Alien Children (UAC) in the custody of the Office of Refugee and
Resettlement (ORR)

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
All UC residing at the facility were eligible to participate.
Briefly, a convenience sample of administrative “pods”, each
representing a group of 12 children housed together, was
selected. Sample size was calculated to provide
representativeness to the total shelter population. The objective of
this investigation was to estimate the prevalence of Streptococcus
pneumoniae carriage in residents of the shelter and to identify
factors associated with carriage related to transit and custody
prior to arrival.
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal swab samples were requested from all selected shelter
residents. Samples were pneumococcus identified by susceptibility to
optochin and bile solubility. Serotypes were determined using the
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Quellung reaction.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
192
Total No. Sampled/Eligible to Respond (B): 232
Response Rate (A/B):
82.8

(Additional Data Collection Instrument sections may be added if necessary.)

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
Data Collection Instrument
Name
Respiratory Illness_Case
Investigation Form
Respiratory
Illness_Hospitalized Case
Investigation Form
Respiratory Illness_Carriage
Assent Form

Type of
Respondent
Healthcare staff

No.
Respondents
(A)
23

Healthcare staff

3

Unaccompanied 192
Children

No. Responses
per Respondent
(B)
1

Burden per
Response in
Minutes (C)
30

Total Burden
in Hours
(A x B x C)/60*
12

1

30

2

1

5

16

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 4 of 4

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014013-XXX
2014-068

HHS/Administration for Children and Families (ACF)/Office of Refugee
Resettlement (ORR)
Pneumonia cluster in an Office of Refugee Resettlement/DOD Unaccompanied
Alien Children’s Shelter—Texas, 2014

Purpose of Investigation: (Use 1. Determine incidence and etiology of acute lower respiratory tract infections and other
as much space as necessary)
health conditions as feasible
2. Estimate incidence of influenza-like illness and characterize subtypes circulating in
shelter
3. Estimate prevalence of Streptococcus pneumoniae carriage in the shelter and
characterize serotypes
4. Describe existing health conditions among unaccompanied children in the shelter that
may impact the spread of respiratory infection
5. Identify risk factors for severe acute respiratory disease among shelter children
6. Assess and implement disease control and prevention measures
Duration of Data Collection: 8 days
Date Began:
July 23, 2014
Date Ended:
July 30, 2014
Lead Investigator
Name:
Steve Waterman
CIO/Division/Branch:
NCEZID/DGMQ
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Respiratory Illness_Case Investigation Form and Respiratory Illness_Interview
Assent Form
Type of Respondent
General public
Other (describe):

Healthcare staff
Federal staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
A descriptive study was conducted to identify the primary agent
and source of the outbreak. Traceback of contacts and travel
history were completed to identify risk factors for exposure.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Face-to-face interviews were conducted with ill case patients to
identify contacts and interactions with ill persons in cluster and to
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
ascertain travel history prior to arriving at shelter. These interviews
were used to complete questions 1-20.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Questions 21 to the end of the form were completed by using the shelter
clinic’s records. Federal staff abstracted medical records.
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
8
Total No. Sampled/Eligible to Respond (B): 8
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Hospitalized Case Investigation Form

Healthcare staff
Laboratory staff
Federal staff abstracted patient medical records

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
We reviewed medical records of hospitalized UC.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): For hospitalized UC, inpatient medical charts were reviewed, and data
was abstracted to complete the form.
Page 2 of 7

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
2
Total No. Sampled/Eligible to Respond (B): 2
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Carriage Assent Form

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
This form was used to document verbal consent/assent for
interviews of the ill case patients and for obtaining
nasopharyngeal and/or throat swabs.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
This was conducted to evaluate potential etiologies in children with
acute lower respiratory infection and/or influenza-like illness.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
A personal interview was conducted to receive consent/assent.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
For each assenting child, a nasopharyngeal and an oropharyngeal swab
were obtained for processing on the Taqman Array Card, a multipathogen detection tool that uses real-time PCR for the rapid,
simultaneous detection of over 21 respiratory pathogens.
Environmental Sample
Other (describe):

Page 3 of 7

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Response Rate (if applicable)
Total No. Responded (A):
8
Total No. Sampled/Eligible to Respond (B): 8
Response Rate (A/B):
100%

Data Collection Instrument 4
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Rapid Environmental Health Assessment

Healthcare staff
Shelter management staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe): This form/checklist was used to complete the rapid environmental
health assessment for the shelter by the Epi-Aid team.
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Interviews conducted with shelter management staff.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Form/checklist also completed via facility tour and observation.
Response Rate (if applicable)
Total No. Responded (A):
1
Total No. Sampled/Eligible to Respond (B): 1
Response Rate (A/B):
100%
Data Collection Instrument 5
Name of Data Collection Instrument:
Type of Respondent
Page 4 of 7

Respiratory Illness_Infection Control Assessment

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
General public
Other (describe):

Healthcare staff
Shelter management staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
This form/checklist was used to perform a rapid assessment of
infection control policies and practices of the shelter by the Epi-Aid
team.
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Interviews conducted with the healthcare and shelter management
staff.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Form/checklist also completed via facility tour and observation of staff
practices.
Response Rate (if applicable)
Total No. Responded (A):
1
Total No. Sampled/Eligible to Respond (B): 1
Response Rate (A/B):
100%
Data Collection Instrument 6
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Respiratory Illness_Carriage Assent Form

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Page 5 of 7

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
This was completed to estimate the prevalence of Streptococcus
pneumoniae carriage in unaccompanied children at the shelter.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
All children residing at the shelter on July 24, 2014 were invited to
participate in the investigation of pneumococcal carriage. A trained clinic
staff member inserted a flexible wire Rayon-tipped swab to the posterior
pharynx and collected the nasopharyngeal specimen to evaluate for
Streptococcus pneumoniae carriage. The swabs were processed and
transported to CDC for pneumococcal isolation and serotyping.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
106
Total No. Sampled/Eligible to Respond (B): 119
Response Rate (A/B):
89%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Respiratory Illness_Case
Patients
8
1
Investigation Form
Respiratory
Patients
8
1
Illness_Interview Assent
Form
Respiratory
Patients
2
1
Illnes_Hospitalized Case
Investigation Form
Respiratory Illness_Carriage Patients
106
1
Assent Form
Page 6 of 7

Burden per
Response in
Minutes (C)
30

Total Burden
in Hours
(A x B x C)/60*
4

10

2

30

1

5

9
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Respiratory Illness_Rapid
Environmental Health
Assessment
Respiratory Illness_Infection
Control Assessment

Other (shelter
management
staff)
Healthcare
staff and
other (shelter
management
staff)

1

1

480

8

1

1

480

8

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 7 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation:
(Use as much space as
necessary)

2014013-XXX
2014-070
HHS/Administration for Children and Families (ACF)/Office of Refugee
Resettlement (ORR)
Pneumonia cluster in Office of Refugee Resettlement/DOD Unaccompanied
Alien Children’s Shelters—Texas, 2014
A surge of Unaccompanied Alien Children (UAC) entered the United States
through the southern border with Mexico in 2014. Between January and June of
2014, approximately 50,000 minors were found along the southern border,
exceeding the total number of children identified in 2013. Following initial
screening, the majority of UACs are being processed through the U.S. Customs
and Border Protection (CPB) Processing Center(s). Once UACs are processed by
CBP, custody is turned over to HHS/Administration for Children and Families
(ACF)/Office of Refugee Resettlement (ORR) for placement in shelters or
facilities operated and managed by ACF/ORR until other arrangements are made.
Following an invitation to CDC by ORR to investigate clusters of respiratory
illnesses in the Naval Base Ventura County temporary shelter and an ORR
permanent shelter in Texas, CDC was informed of cases of severe pneumonia
requiring hospitalization among UC while they were residing in the Nogales,
Arizona, CBP Processing Center (one case hospitalized) and an additional 5
hospitalized cases were identified at other ORR shelters located in Texas and
Oklahoma. One of the new cases from Texas, while culture negative, had S.
pneumoniae detected by antigen testing of pleural fluid. The circumstances and
risk factors associated with these clusters were unclear. The evidence continued
to suggest that exposure to this pneumococcal strain occurred early during
processing of these children and that potentially persons could be carrying or
incubating disease in other shelters. In addition, current surveillance might not
have been detecting current cases. Although CDC recommended to ORR that all
children residing in temporary or permanent ORR shelters receive 13-valent
pneumococcal conjugate vaccine (PCV13) in addition to other vaccines, there
was a need to investigate and better characterize this outbreak wherever clusters
occur, while the vaccination strategy is being implemented. There was a
continued need to better describe this situation and implement appropriate
interventions, as well as determine if PCV13 is needed on an ongoing basis.

An urgent investigation was conducted is needed to determine the scope of the
outbreak, identify any potential sources of infection early during the processing
of these children, identify predisposing factors and other risk factors for these
respiratory illnesses, determine the primary agent of the outbreak, identify
contacts of ill children, assist with establishing better surveillance in the facility,
and implement appropriate measures to control and limit respiratory illnesses in
this vulnerable population.
Duration of Data Collection: 5 days
Date Began:
7/28/2014
Date Ended:
8/1/2014
Lead Investigator
Name:
Cynthia Whitney, MD
Page 1 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
CIO/Division/Branch:
Email Address:
Telephone No.:
Mail Stop:

NCIRD/DBD/RDB
[email protected]
404-639-4727
C25

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument: Respiratory Illness_Case Investigation Form
Type of Respondent
General public
Healthcare staff
Laboratory staff
Patients
Restaurant staff
Other: (describe) Federal staff review of electronic records
Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Descriptive study of the etiologies and clinical features of
respiratory disease among a cohort of residents of an ORR shelter.
Cross-sectional Study (describe):
Cohort Study (describe):
Retrospective cohort study to determine transit-related risk factors
for respiratory disease among a cohort of residents of an ORR
shelter.
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
On four individuals identified with influenza-like-illness (ILI)
during the period of July 28 to August 1, nasopharyngeal and
oropharyngeal swabbing was performed for etiologic pathogen
detection using molecular methods.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-andPencil Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Electronic medical records were reviewed to identify
children with ILI between June 25 and July 28, and chart
abstraction was performed to obtain the required
information.
Biological Specimen Sample On four individuals identified with influenza-like-illness (ILI) during the
period of July 28 to August 1, nasopharyngeal and oropharyngeal swabbing was performed for etiologic
pathogen detection using molecular methods
Environmental Sample
Other (describe):
Page 2 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Response Rate (if applicable)
Total No. Responded (A):
Total No. Sampled/Eligible to Respond
(B):
Response Rate (A/B):

40
40
100%

Data Collection Instrument 2
Name of Data Collection Instrument: Respiratory Illness_Carriage Assent Form
Type of Respondent
General public
Healthcare staff
Laboratory staff
Patients
Restaurant staff
Other: (describe) Unaccompanied child residents of an ORR shelter.
Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe): Investigation to determine the prevalence, prevalent serotypes of,
and risk factors for S. pneumoniae nasopharyngeal carriage among
residents of an ORR shelter.
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal swabbing was performed in order to detect and
identify the serotype of S. pneumoniae carriage.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-andPencil Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Total No. Sampled/Eligible to Respond
(B):
Response Rate (A/B):

Page 3 of 4

119
141
84%

Form Updated: 5/29/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Complete the following burden table. Each data collection instrument should be included as a separate
row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection
Type of
Respondents per Respondent
Instrument Name
Respondent
(A)
(B)
Case Investigation FormPatient
40
1
Respiratory Illness
Carriage Assent FormPatient
119
1
Respiratory Illness

Burden per
Response in
Minutes (C)
30

Total Burden
[in hours;
(AxBxC)/60]
20

5

10

Return completed form and a blank copy of each final data collection instrument within 5 business days of data
collection completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 4 of 4

Form Updated: 5/29/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014014-XXX
2014-071
Sierra Leone Ministry of Health, Ministry of Health & Sanitation, Disease Prevention and
Control
Undetermined Sources and Risk Factors for an Ebola Hemorrhagic Fever Outbreak—
Sierra Leone, 2014
Purpose of Investigation: (Use The investigation follwed a case series study design, where case report forms (see
as much space as necessary) Appendix 1) were collected for every patient meeting the suspect case definition criteria.
Forms were collected through interview of patients or family members if patients have
died or are infants, in either French or the local language. Relevant clinical data, including
the patient’s date of onset, date of death, hospitalization and funeral information, and
contacts that the patient had prior to developing illness all are collected, in an effort to
determine the risk factors that led to this patient’s infection. If diagnostic testing confirms
that this patient has EVD, a separate contact tracing form (see Appendix 2) is completed
to collect information of people who had direct unprotected contact with the patient while
they were ill and prior to treatment in a facility with barrier nursing. These contacts were
then followed daily for onset of fever and other EVD symptoms, and were investigated as
cases and treated under barrier nursing precautions if they develop illness.
Duration of Data Collection: 90 days
Date Began:
6/27/2014
Date Ended:
10/19/2014
Lead Investigator
Name:
Barbara Knust
CIO/Division/Branch:
NCEZID/DHCPP
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Ebola_Case Investigation Form
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
The investigation followed a case series study design, where case
report forms were collected for every patient meeting the suspect
case definition criteria.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
When possible, diagnostic testing was used to confirm Ebola virus
infection or rule out infection. Laboratory testing was not performed
by CDC personnel, but laboratory results were recorded.
Other (describe):
Data Collection Mode (check all that apply)
Page 1 of 3

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Hospital records were used to collect relevant clinical information in the
case report form
Biological Specimen Sample
Blood or oral swab specimens were collected from patients to confirm or
rule out Ebola virus infection. Laboratory testing were not be performed
by CDC personnel, but laboratory results were recorded.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
3600
Total No. Sampled/Eligible to Respond (B): 3600
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Ebola_Contract Tracing Form

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Contacts of confirmed Ebola case-patients were identified and
information about their location and type of contact was gathered.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Page 2 of 3

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
2000
Total No. Sampled/Eligible to Respond (B): 2000
Response Rate (A/B):
100%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Ebola_Case Investigation
General
3600
1
Form
Public
Ebola_Contract Tracing
General
2000
1
Form
Public

Burden per
Response in
Minutes (C)
25

Total Burden
in Hours
(A x B x C)/60*
1500

3

100

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014015-XXX
2014-072
Kansas Department of Health and Environment
Undetermined risk factors for transmission of Human Parechovirus 3 among severely ill
neonates and infants – Kansas and Missouri, 2014

Purpose of Investigation: (Use The Kansas Department of Health and Environment requests CDC assistance with an
as much space as necessary) investigation to 1) assist local public health authorities with control of HPeV3
transmission among neonates and infants; 2) assist in the systematic collection of data to
identify routes of transmission and risk factors for infection; 3) further define the scope of
the outbreak across the affected public health jurisdictions.
Duration of Data Collection
Date Began:
8/13/2014
Date Ended:
11/11/2014
Lead Investigator
Name:
Claire Midgley
CIO/Division/Branch:
NCIRD/DVD
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Parechovirus_Chart Abstraction Form

Healthcare staff
Laboratory staff
State Health Departments or delegates

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
This was a descriptive study to systematically collect information
about clinical illness and potential exposures associated with
HPeV3 illness in order to identify risk factors and modes of
transmission. Parts A-C of this chart abstraction form were used
to collect information about the mother and infant from the
infant’s birthing hospital. Part D of the chart abstraction form
was used to collect clinical and laboratory testing information on
the patient when hospitalized with HPeV3.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Page 1 of 4

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Parts A-C: Medical records of confirmed case-patients were identified for
abstraction of key clinical information during birth. The mother’s labor,
delivery, and follow-up medical records were also abstracted to identify
risk factors and mode of transmission. These data were collected from
birth hospitals by state health departments, in conjunction with staff at the
individual hospitals.
Part D: Medical records of confirmed case-patients were identified for
abstraction of key clinical information, from the hospital where the infant
was diagnosed with HPeV3 (Facility A). This work was performed by
delegates of the state health departments.
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
62
Total No. Sampled/Eligible to Respond (B): 67
Response Rate (A/B):
93%

Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Parechovirus_Family Interview Questionnaire

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
This is a descriptive study to systematically collect information
about clinical illness and potential exposures associated with
HPeV3 illness in order to identify risk factors and modes of
transmission. Family interviews were carried out to understand
illness in the week preceding hospitalization, and to investigate
possible contacts.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Page 2 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Families of patients were interviewed in-person, where possible
Telephone Interview (describe):
Families of patients were interviewed by telephone if needed
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
26
Total No. Sampled/Eligible to Respond (B): 40
Response Rate (A/B):
65%

Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Parechovirus_Patient_Sibling Diaper Collection

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
This is a descriptive study to systematically collect information
about clinical illness and potential exposures associated with
HPeV3 illness in order to identify risk factors and modes of
transmission. During family interviews, a diaper was collected
from patients and their siblings to investigate whether siblings
were also infected and to investigate the length of shedding of
HPeV3 in stool
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Biological samples from siblings and suspect cases were collected by
state health department staff and sent to the laboratory at Facility A to
confirm case status, following local policies and procedures.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Page 3 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Soiled diaper collection for HPeV3 testing
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
26
Total No. Sampled/Eligible to Respond (B): 26
Response Rate (A/B):
100%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Medical Chart Abstraction
State Health
4
5.5
Form_Parechovirus (Parts A, Department
B,C)
(or delegate)
Medical Chart Abstraction
State Health
2
20
Form_Parechovirus (Parts D) Department
(or delegate)
Family Interview
General
26
1
Questionnaire_ Parechovirus Public
Patient and Sibling Diaper
General
26
1
collection
Public

Burden per
Response in
Minutes (C)
45/60

Total Burden
in Hours
(A x B x C)/60*
17

20/60

14

30/60

13

5/60

2

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 4 of 4

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014016-XXX

2014-075
Ministry of Health, Democratic Republic of Congo

Undetermined Sources and Risk Factors for an Ebola Hemorrhagic Fever Outbreak—
Democratic Republic of Congo, 2014
Purpose of Investigation: (Use On August 24, 2014, the DRC Ministry of Health (MoH) announced an Ebola outbreak in
as much space as necessary) Boende Health Zone, Tshuapa District, Equateur Province. As of August 28, 24 cases of
suspect Ebola hemorrhagic fever (EHF) were identified, including 13 deaths (case fatality
rate of 54%). Eight blood specimens from suspect cases were sent to the National Institute
for Biomedical Research (INRB) in Kinshasa and to the International Centre for Medical
Research of Franceville (CIRMF) in Gabon for testing. INRB confirmed Ebola virus in
4/8 specimens and CIRMF confirmed Ebola virus in 6/8 specimens. Zaire ebolavirus was
the causative species, and DNA sequencing results confirmed that this was a different
strain of Zaire ebolavirus from the strain circulating in West Africa.
On August 29, 2014, the DRC MoH requested assistance from the CDC to halt and
prevent virus transmission as part of the coordinated response efforts.
The objectives of the investigation were to collect necessary suspected case and contact
information from all affected villages and areas. The investigation followed a case series
study design, where WHO-provided case report forms were collected for every patient
meeting the suspect case definition criteria. A separate WHO-provided contact tracing
form was completed to collect information regarding people who had direct unprotected
contact with the patient while they were ill and prior to treatment in a facility with barrier
nursing.
Community volunteers were widely used to conduct contact tracing activities. A survey
designed to assess the knowledge of these community volunteers was developed and
administered to a convenience sample of community volunteers. Additionally, a survey to
assess infection control materials in present in health facilities was conducted amongst a
convenience sample of facilities. The results from these surveys will be delivered to the
Ministry of Health and used to guide future response efforts.
Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

September 11, 2014
October 28, 2014
Andrea McCollum
NCEZID / DHCPP / PRB

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

RECO Interview

Healthcare staff
Laboratory staff
Patients
Relay communautaires (community educators / volunteers)

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Page 1 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Descriptive Study (describe):

Descriptive assessment of community volunteers involved in
contact tracing efforts for the ebola outbreak response.

Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
18
Total No. Sampled/Eligible to Respond (B): 50
Response Rate (A/B):
0.36
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Health Facility Assessment

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Assessment of health facilities in the context of infection control
and ability to care for ebola patients during an ongoing outbreak
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Page 2 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
5
Total No. Sampled/Eligible to Respond (B): 20
Response Rate (A/B):
0.25
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Type of
Respondents
per Respondent
Data Collection Instrument
Name
Respondent
(A)
(B)
RECO Interview
Community
18
1
volunteer
Health Facility Assessment
Healthcare
5
1
worker

Burden per
Response in
Minutes (C)
10

Total Burden
in Hours
(A x B x C)/60*
3

10

1

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014017-XXX
2014-076
California Department of Public Health

Undetermined risk factors and mode of transmission for bloodstream
infections among hemodialysis patients—California, 2014
Purpose of Investigation: (Use On May 9, 2014, the California Dept. of Public Health (CDPH) notified CDC of 6
as much space as necessary) cases of Burkholderia cepacia bloodstream infections (BSIs) among hemodialysis
patients in a single outpatient dialysis center in 2014. Additional case finding
conducted by CDPH revealed 2 cases of Stenotrophomonas maltophilia BSIs
among patients at the center in late 2013. CDC was subsequently notified of 2
cases of S. maltophilia and 1 case of B. cepacia BSIs at another dialysis center
belonging to the same company. All 11 cases appeared to be in patients whose
dialyzers were reused and reprocessed. Environmental cultures performed in the
facility with the index cluster identified B. cepacia from a dialyzer preprocessing
machine. At the second facility, S. maltophilia was recovered from a culture taken
from a connector at the sink used to rinse dialyzers prior to reprocessing.
A broader search of BSIs caused by similar waterborne organisms that could be
introduced during dialyzer reprocessing (B. cepacia, Pseudomonas,
Stenotrophomonas, Proteus, Morganella, Serratia) during January to August 2014
revealed 18 potential cases across multiple facilities within the same company. A
search for similar BSIs in facilities belonging to other companies was not
conducted. Because of the scope of the investigation, concern for ongoing
transmission, and CDC’s expertise in infection prevention in dialysis settings,
CDPH requested CDC assistance with an urgent public health investigation.
Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

3 weeks
9/18/2014
10/7/2014
Chris Edens
NCEZID/DHQP/PRB

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Chart Abstraction Form
Type of Respondent
General public
Other (describe):

Healthcare staff
CDPH staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
1:3 case control study to investigate risk factors of BSIs
Page 1 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Performed for case control study
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
3
Total No. Sampled/Eligible to Respond (B): 3
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Reuse and reprocessing checklist

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Performed observations of dialysis facility practices
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Collected swabs and water samples from 6 facilities
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Observed facility staff perform dialysis protocols and procedures
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Page 2 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Collected swabs and water samples from 6 facilities
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
6 facilities
Total No. Sampled/Eligible to Respond (B): 6 facilities
Response Rate (A/B):
1.0

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Chart Abstraction Form
Patient
3
119
medical chart
Reuse and reprocessing
Facility staff 6 total
1
checklist
facilities

Burden per
Response in
Minutes (C)
12

Total Burden
in Hours
(A x B x C)/60*
72

20

2

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014018-XXX
2014-077
Colorado Department of Public Health and Environment (CDPHE)
Undetermined etiology, mode of transmission, and risk factors for pediatric cluster of
neurologic symptoms following respiratory illness, Colorado, 2014
On September 16, 2014, CDC was notified by Colorado Department of Public Health and
Environment (CDPHE) of nine cases of acute central nervous system disease among
pediatric patients. The cases were identified during August 4–September 17, 2014 among
children aged 1–18 years (median age 9 years), most from the greater Denver
metropolitan area. The patients suffered acute neurologic symptoms including cranial
nerve palsies, weakness in one or more limbs, headache, and photophobia and all were
hospitalized. Some patients reported a febrile respiratory illness during the 2 weeks
preceding development of neurologic symptoms. Cerebrospinal fluid (CSF) analysis
demonstrated increased white blood cell count (pleocytosis). Magnetic resonance imaging
(MRI) for all patients showed significant demyelinating lesions in the spinal cord, brain,
and/or cranial nerves. Six patients had tested positive for rhinovirus/enterovirus via
respiratory virus panels. Two of the six cases tested positive for EV-D68 through
confirmatory testing at CDC’s Picornavirus Laboratory.
The initial cases had been reported from one hospital which indicated that this was an
unusual number of cases of this syndrome. Some cases required treatment in an intensive
care unit and all were hospitalized. Data collection focused on this facility, however as
CDPHE released a health advisory, one case from a different hospital was reported and
included in our investigation. Ultimately 13 cases were investigated who met the case
definition and were included in the final analysis.
With CDPHE, CDC investigated all of the confirmed cases reported from Colorado,
performed chart reviews, summarized the collected data and disseminated this information
through an MMWR.
Objectives of this mission were:
1.
Assist the state and local health department with the investigation including to
better characterize the common clinical presentation among reported patients consistent
with neurologic syndromes being currently investigated.
2.
Characterize the epidemiology of the acute neurologic syndrome cases.
3.
Evaluate potential non-infectious and infectious etiologies including through
laboratory testing for enteric respiratory and zoonotic pathogens (including circulating
viruses enterovirus-D68, West Nile Virus, and other possible pathogens).
4.
Develop a standard approach within this outbreak, to investigate cases of acute
myelitis/AFP in order to apply to other cases as they are reported, as requested by the
Colorado department of health in their health alert.

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

Page 1 of 3

One data collection tool was used (a medical chart abstraction form).
3 months
9/21/2014
12/21/2014
Drs. Dan Pastula and Negar Aliabadi
NCEZID/ADB and NCIRD/DVD

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Paralysis_Medical Chart Abstraction Form
Type of Respondent
General public
Other (describe):

Healthcare staff
Federal Staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
This is a descriptive study to systematically collect information
about clinical illness and potential exposures associated with
neurologic illness in order to identify risk factors and modes of
transmission.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Chart abstraction of case-patients was used to collect diagnoses,
symptoms, signs, imaging results and treatment information about casepatients.
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
13 chart abstractions
Total No. Sampled/Eligible to Respond (B): 13/13
Response Rate (A/B):
100

Page 2 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
Data Collection Instrument
Type of
Respondents No. Responses per
Name
Respondent
(A)
Respondent (B)
Paralysis_Medical Chart
Hospital
1
2
Abstraction Form
Staff
Paralysis_Medical Chart
Federal Staff 3
3.7
Abstraction Form

Burden per
Response in
Minutes (C)
180

Total Burden
in Hours
(A x B x C)/60*
6

180

NA

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014019-XXX
2014-078
California Department of Public Health

Undetermined source, mode of transmission, and risk factors for Pseudomonas aeruginosa
infections and deaths among neonatal intensive care unit (NICU) patients — California,
2013-2014.
Purpose of Investigation: (Use Pseudomonas spp. are a type of bacteria found in the environment, including in water
as much space as necessary) sources. Serious Pseudomonas infections usually occur in hospitalized individuals or
individuals with weakened immune systems. Invasive infections can lead to severe illness
and death. On September 15, 2014, CDC was notified of ongoing positive Pseudomonas
aeruginosa cultures among patients in a neonatal intensive care unit (NICU) beginning in
September 2013. Two infants died in November 2013 with P. aeruginosa bloodstream
infections at which time the state was notified. Environmental cultures from water faucets
in the NICU identified P. aeruginosa isolates, but none of the strain types matched patient
isolates. In response, the facility had the water system evaluated and performed
remediation. No further cases were identified until June 2014 when a new case of
respiratory colonization was identified. Cases of colonization and infection continued
through August 2014. On September 18, 2014 the California Department of Public Health
(CDPH) notified CDC of an additional P. aeruginosa bacteremia and death in a NICU
patient. CDPH requested CDC assistance with an on-site investigation on September 23,
2014 to determine the source and modes of transmission of P. aeruginosa infections in the
NICU in order to prevent further cases and deaths. The CDC Epi-Aid team identified 31
cases of pseudomonas positive culture from June 1, 2013 to October 7, 2014.
Duration of Data Collection: 15 days
Date Began:
09/25/2014
Date Ended:
10/09/2014
Lead Investigator
Name:
Cara Bicking Kinsey
CIO/Division/Branch:
OPHSS/CSELS/EWB
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Pseudomonas_Chart Abstraction Form
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Investigator- Federal Staff; Electronic Medical Record

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Thirty one cases of positive pa cultures were matched on birth
weight with 31 controls from the same population of NICU
patients.
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Page 1 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe): Electronic medical record
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
1 (3 records abstracted by 1 federal staff investigator)
Total No. Sampled/Eligible to Respond (B): 1
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Pseudomonas_Health Care Practices Audit Forms

Healthcare staff
Investigator- Federal Staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Page 2 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Investigators observed health care practices in the unit affected by the
outbreak including hand hygiene practices, PPE and Contact isolation
practices, and practices related to Central Venous Catheter maintenance
and insertion.
Response Rate (if applicable)
Total No. Responded (A):
1
Total No. Sampled/Eligible to Respond (B): 1
Response Rate (A/B):
100%
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Type of
Respondents
per Respondent
Data Collection Instrument
Name
Respondent
(A)
(B)
Pseudomonas_Chart
Federal Staff 1
1
Abstraction Form
Pseudomonas_Health Care
Federal Staff 1
1
Practices Audit Forms

Burden per
Response in
Minutes (C)
60

Total Burden
in Hours
(A x B x C)/60*
1

90

2

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014020-XXX
Sierra Leone Ministry of Health

A Rapid Anthropological Assessment of Community-Based Deaths: Understanding Why
Ebola Deaths Occur at Home in Urban Montserrado, Liberia
Purpose of Investigation: (Use The number of bodies believed to be the result of an Ebola-related death rose to a
as much space as necessary) maximum in week 38 (September 15), with 380 bodies collected, and then declined to 160
by week 43 (October 20) and have declined since that time. In November and early
December 2014, the International Federation of the Red Cross (IFRC) collected
approximately 80-100 dead bodies per week in urban Montserrado County. About 30% of
those bodies were Ebola positive. Of those, about half came from Ebola Treatment Units
and the other half are from homes in the community. The presence of Ebola positive
bodies in homes indicates a failure of Ebola case finding and prevention efforts. This
assessment was conducted to document factors at the household-, community-, and
responder-levers that contribute to delayed care-seeking for Ebola in order to contribute to
strategies to reduce the number of in-home Ebola deaths.
Duration of Data Collection: 10 days
Date Began:
12/22/2014
Date Ended:
12/31/2014
Lead Investigator
Name:
Denise Roth Allen
CIO/Division/Branch:
CGH/DPDM/Malaria
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Topic Guide for Community Leaders Focus Group
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Rapid Anthropological Assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Page 1 of 5

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Focus Group Discussion
Response Rate (if applicable)
Total No. Responded (A):
25
Total No. Sampled/Eligible to Respond (B): 25
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Topic Guide for Community Member Focus Group

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Rapid Anthropological Assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Focus Group Discussion
Response Rate (if applicable)
Total No. Responded (A):
Page 2 of 5

47
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Total No. Sampled/Eligible to Respond (B): 47
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Topic Guide for Contact Tracer Focus Group

Healthcare staff
Laboratory staff
Persons who conduct tracing of Ebola contacts

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Rapid Anthropological Assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Focus Group Discussion
Response Rate (if applicable)
Total No. Responded (A):
3
Total No. Sampled/Eligible to Respond (B): 5
Response Rate (A/B):
60%

Data Collection Instrument 4
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Page 3 of 5

Topic Guide for Supervisors of Contact Tracers Key Informant Interviews

Healthcare staff
Laboratory staff
Persons who supervises contact tracers

Patients

Restaurant staff

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Rapid Anthropological Assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Key Informant Interview (non-survey mode)
Response Rate (if applicable)
Total No. Responded (A):
2
Total No. Sampled/Eligible to Respond (B): 2
Response Rate (A/B):
100%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Topic Guide for Community General
25
1
Leaders Focus Group
public
Topic Guide for Community General
47
1
Member Focus Group
public
Topic Guide for Contact
Persons who 5
1
Tracer Focus Group
conduct
contact
tracing of
Ebola
respondents

Page 4 of 5

Burden per
Response in
Minutes (C)
90

Total Burden
in Hours
(A x B x C)/60*
38

90

71

60

5

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Topic Guide for Supervisors
of Contact Tracers Key
Informant Interviews

Supervisors
of contact
tracers

2

1

40

2

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 5 of 5

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation: (Use
as much space as necessary)

2014020-XXX
Sierra Leone Ministry of Health
Formative Research on Burial Practices in Sierra Leone
On March 21, 2014, the World Health Organization and the Ministry of Health (MoH) of
Guinea reported an outbreak of Ebola viral disease (EVD), and shortly thereafter clinical
cases were also reported in Liberia. By May, the first cases identified in Sierra Leone were
reported. The outbreak expanded to Nigeria on July 25th and Senegal on August 29th. The
outbreak continues to accelerate in West Africa and is unprecedented in size. As of
September 14th, there is a combined total of 5453 cases and 2624 deaths (case-fatality rate
= 48%) reported in affected countries.
Major challenges faced by all partners in the efforts to control the outbreak include its
wide geographic spread, weak health-care infrastructures, and community mistrust and
resistance.
In June 2014, the World Health Organization, and the Ministries of Health in affected
countries requested additional support from CDC and other partners, necessitating the
deployment of CDC staff members to West Africa to aid in outbreak investigation and
control.
In August, the World Health Organization declared the EVD outbreak an international
public health emergency. Persistence and magnitude of the outbreak necessitates highlevel, regional and international coordination to bolster response efforts among involved
and neighboring nations and other response partners in order to control further infection
and prevent outbreaks in other countries.Sierra Leone, Ministry of Health and Sanitation,
has requested continued CDC assistance with the investigation to identify sources and risk
factors for Ebola infection in order to implement specific prevention and control
measures. As the initial outbreak expanded, country-specific GenICs were submitted and
approved by OMB for data collections in Guinea (GenIC No. 2014010-XXX, exp.
9/25/2014), Liberia (GenIC No. 2014011-XXX, exp. 10/6/2014), and Sierra Leone
(GenIC No. 2014-014, exp. 10/19/2014). As these GenICs have expired or will soon
expire, an OMB International Emergency Clearance Package has been submitted to
request OMB clearance for data collections related to basic epidemiological objectives.
Data collected under the Emergency Clearance will be used to maintain a centralized
database for data collected from all outbreak sites, and to assist in contact tracing, case
report collection, and patient or family interviews. The Emergency Clearance includes
already developed data collection forms to be used for well-defined data collection
activities necessary for continued prevention and control measures.
This GenIC sought OMB approval for additional urgent investigations necessary for
prevention and control of the current EVD outbreak that were not included in the
Emergency Clearance because final forms are not yet available. For example, prevention
and control recommendations related to cultural practices and religious beliefs that
influence disease transmission are needed; these factors were not well-understood. CDC
assisted WHO and the Sierra Leone Ministry of Health with an investigation of cultural
and religious beliefs that influence disease transmission during home care and funerals of
EVD cases. Data were collected via focus groups with key informants, cases, and family
members.

Duration of Data Collection:
Date Began:
Date Ended:
Page 1 of 3

10/13/2014
11/1/2014
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Lead Investigator
Name:
CIO/Division/Branch:
Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Ebola_Burial Practices Focus Group Guide
Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Knowledge, attitude and practice qualitative study
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Focus group discussion (avg. 8 attendees per group) lead by trained
moderator and 2 note takers.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
373
Total No. Sampled/Eligible to Respond (B): 373
Response Rate (A/B):
100
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
Data Collection Instrument
Type of
No.
No. Responses
Name
Respondent
Respondents
per Respondent
Page 2 of 3

Burden per
Response in

Total Burden
in Hours

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
(A)
Ebola_Burial Practices
Focus Group Guide

General
public

373

(B)
1

Minutes (C)
75

(A x B x C)/60*
467

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 3 of 3

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2014020-XX

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

3 months
Oct 1 2014
Dec 31 2014

Sierra Leone Ministry of Health

Evaluating Health Care Worker (HCW) and Ebola Virus Disease (EVD) exposure risk in
Guinea, Liberia, and Sierra Leone
Purpose of Investigation: (Use To identify exposures preceding HCW EVD infection and obtain a more accurate
as much space as necessary) estimate of the burden of disease among HCW.

Ben Park, Ryan Fagan
DGHQ

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Healthcare Worker - Ebola Virus Disease Exposure Risk Report (CDC/WHO)
Type of Respondent
X General public
Other (describe):

X Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
X Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
X Other (describe):
Case series
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
X Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
Questions on forms are asked of respondents
X Telephone Interview (describe):
Questions on forms are asked of respondents
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Page 1 of 2

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Response Rate (if applicable)
Total No. Responded (A):
11
Total No. Sampled/Eligible to Respond (B): 11
Response Rate (A/B):
100%

(Additional Data Collection Instrument sections may be added if necessary.)

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Healthcare Worker - Ebola
health care
11
1
Virus Disease Exposure Risk facility staff
Report (CDC/WHO)
proxy for
HCW-patient

Burden per
Response in
Minutes (C)
30

Total Burden
in Hours
(A x B x C)/60*
6

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 2 of 2

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation: (Use
as much space as necessary)

2014022-XXX
2015-002
Texas Department of Health Services
Investigation of Ebola Virus Disease – Ohio, October 2014

On September 29, 2014, the Texas Department of State Health Services reported
the first case of Ebola virus disease (Ebola) diagnosed in the United States to the
Centers for Disease Control and Prevention (CDC). As part of the contact tracing
investigation, Dallas County Health and Human Services monitored members of
the health care team that provided care to the index case-patient for signs and
symptoms of Ebola.
An intensive care nurse who had provided direct care to the index-patient on most
days between September 30 and October 8 boarded a plane departing Dallas, TX
for Cleveland, OH on Friday, October 10. Her final destination was Akron, OH,
where she stayed with her mother and stepfather and made preparations for her
upcoming wedding. Though the timing is unclear, she developed constitutional
symptoms of malaise and fatigue prior to departing Ohio on the evening of
Monday, October 13. She fastidiously monitored her body temperature and was
reportedly afebrile during this interval.
Soon after the nurse returned to Dallas, however, she developed a fever of 100.5⁰
F. After alerting local public health authorities, she drove herself to the Texas
Health Presbyterian Hospital Emergency Department for evaluation in the early
morning hours of October 14th. Later that day, the Texas State Public Health
Laboratory reported that a sample of her blood had tested positive for Ebola virus
by reverse transcriptase-polymerase chain reaction testing. The CDC Viral Special
Pathogens Branch laboratory confirmed this result on October 15, and the nurse
was diagnosed with Ebola.
On October 15, the Ohio Department of Health (ODH) requested assistance from
CDC to investigate the case-patient and her contacts; to assess the risk of potential
spread from the patient to household, community, conveyance and hospital
contacts; to identify other possible contacts; to provide recommendations on
appropriate infection control measures to prevent virus transmission as part of the
coordinated response efforts; and to assess and guide regional health care systems
in their preparedness to isolate, stabilize, evaluate, and treat a person suspected of
having Ebola.

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

19 days
October 16, 2014
November 4, 2014
Chris Braden, MD
Director, Division of Foodborne, Waterborne and Environmental Diseases, NCEZID

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Ebola Virus Disease Contact Tracing Form
Page 1 of 6

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Type of Respondent
General public
X Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential community contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Data was collected for community contact risk assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
Questionnaires were administered in person
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
15
Total No. Sampled/Eligible to Respond (B): 15
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Ebola Exposure Assessment Questionnaire for Airline Passengers

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential passenger contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Page 2 of 6

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
X Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):

Data was collected for airline passenger contact risk assessment

Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
X Telephone Interview (describe):
Questionnaires were administered over the phone to all airline
passengers on the two flights who may have had contact with the
case-patient
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
92
Total No. Sampled/Eligible to Respond (B): 92
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Bridal Store Visitor Questionnaire

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential community contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Data was collected for community contact risk assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Page 3 of 6

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
X Telephone Interview (describe):

Questionnaires were administered over the phone to all persons who
visited a bridal store who may have had contact with the case-patient

Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
56
Total No. Sampled/Eligible to Respond (B): 56
Response Rate (A/B):
100%
Data Collection Instrument 4
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Daily Contact Symptom Follow-up Log

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Daily symptom check for all Tier 1, 2A, and 2B contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Daily temperature and symptom checks for all contacts classified in
the higher risk groups
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
X Telephone Interview (describe):
20 respondents had twice daily temperature and symptom checks,
once done in person and once done over the phone.
93 respondents had once daily temperature and symptom checks
done over the phone
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Page 4 of 6

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
113
Total No. Sampled/Eligible to Respond (B): 113
Response Rate (A/B):
100%
Data Collection Instrument 5
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Domestic Animal Questionnaire for Contacts under Active Monitoring

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Questionnaire for all Tier 1 and 2A contacts of a confirmed Ebola case-patient that lived with
domestic animals

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Data collection tool for higher risk contacts that owned domestic
animals
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
Questionnaires were administered in person if higher risk contact
informed contact tracers that they own or live with a domestic
animal
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Page 5 of 6

5
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Total No. Sampled/Eligible to Respond (B): 5
Response Rate (A/B):
100%
(Additional Data Collection Instrument sections may be added if necessary.)

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Ebola Virus Disease Contact Close
15
1
Tracing Form
community
contact
Ebola Exposure Assessment Airline
92
1
Questionnaire for Airline
passenger
Passengers
contact
Bridal Store Visitor
Community
56
1
Questionnaire
contact
Daily Contact Symptom
All contacts
113
20 respondents –
Follow-up Log
who were
38 responses (2x
classified as
daily)
requiring
93 respondents –
daily active
19 responses (1x
monitoring
daily)
Domestic Animal
Contacts
5
1
Questionnaire for Contacts
under Active
under Active Monitoring
Monitoring
who owned
pets

Burden per
Response in
Minutes (C)
45 min

Total Burden
in Hours
(A x B x C)/60*
11.25 hr

20 min

30.67 hr

5 min

4.67 hr

5 min

201.58 hr

5 min

0.42 hr

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 6 of 6

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation: (Use
as much space as necessary)

2014022-XXX
2014-079
Texas Department of Health Services
Investigation of Ebola Virus Disease Importation—Texas, 2014

The first case of Ebola Virus Disease (EVD) in a traveler in the United States was
reported to CDC by the Texas Department of State Health Services (TDSH). This
patient is an adult traveler from Liberia, who arrived in the U.S. from Monrovia on
September 20, 2014. The patient was asymptomatic while traveling to the United
States. The patient developed fever and abdominal pain on September 26th, and
sought medical care at the Emergency Department of Hospital A in Texas and was
discharged on the same day. Two days later, on September 28th, the patient
returned to the same Emergency Department by ambulance, complaining of
continuing fever as well as diarrhea and vomiting. The patient denied having had
any exposure to an Ebola patient, attending or taking part in any burials, or
preparing or eating any wild game (bushmeat). The patient was monitored under
isolation in the Emergency Department, and was subsequently isolated to an ICU
bed with appropriate infection control measures. The initial work-up included a
negative malaria smear. The patient is receiving intravenous fluids and having
moderate fluid losses through vomiting and diarrhea. A blood specimen was sent
to the Texas State Public Health Laboratory and CDC for Ebola RT-PCR testing
on September 29, 2014. RT-PCR results from the CDC Viral Special Pathogens
Branch laboratory were reported as positive on September 30, 2014, and a
diagnosis of EVD was made.
On September 30, 2014, TDSH requested assistance from CDC to investigate this
case, to assess the risk of potential spread from the patient to household,
community, conveyance and hospital contacts, to identify other possible contacts,
to help with community and hospital contact tracing and monitoring efforts for this
patient and any subsequent Ebola cases, and to provide recommendations on
appropriate infection control measures to prevent virus transmission as part of the
coordinated response efforts.

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

36 days
October 1, 2014
November 7, 2014
David Kuhar, M.D.

NCEZID, Division of Healthcare Quality Promotion, Prevention and Response
Branch

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Ebola Virus Disease Contact Questionnaire
Type of Respondent
General public
X Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential community contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Page 1 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Data was collected for community contact risk assessment
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
Questionnaires were administered in person
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
45
Total No. Sampled/Eligible to Respond (B): 45
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Ebola Virus Disease Contact Questionnaire (Revised)

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential community contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
X Other (describe):
Data was collected for community contact risk assessment
(revised in the Field)
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
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Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Data was collected for community contact risk assessment (revised
in the field)
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
6
Total No. Sampled/Eligible to Respond (B): 6
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Ebola Virus Disease Case Contact Questionnaire (Initial)

Healthcare staff
Laboratory staff
Patients
Restaurant staff
The questionnaire was for potential community contacts of a confirmed Ebola case-patient

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Data was collected for health care worker risk assessment for patient 1
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Data was collected for health care worker risk assessment for patient
1
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
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Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
85
Total No. Sampled/Eligible to Respond (B): 85
Response Rate (A/B):
100%
Data Collection Instrument 4
Name of Data Collection Instrument:

Healthcare Worker Interview Form 10/11/2014 (Interactions since 30
September 2014)

Type of Respondent
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Re-interview forms for healthcare workers with ongoing exposure to
patient 1 and with new exposures to patient 2 and 3.
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Re-interview forms for healthcare workers with ongoing exposure to
patient 1 and with new exposures to patient 2 and 3.
X Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Page 4 of 7

282
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
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Total No. Sampled/Eligible to Respond (B): 282
Response Rate (A/B):
100%
Data Collection Instrument 5
Name of Data Collection Instrument:
Type of Respondent
General public
X Other (describe):

Health Care worker Supplemental Interview Form

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Questionnaire for all healthcare workers who had direct patient contact or environmental
exposures (Patient 1, 2, 3)

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Questionnaires were administered to all healthcare workers who were
involved with direct patient care or had potential exposures to
contaminated surfaces (Patient 1, 2, 3)
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
Questionnaires were administered to all healthcare workers who
were involved with direct patient care or had potential exposures to
contaminated surfaces (Patient 1, 2, 3)
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
282
Total No. Sampled/Eligible to Respond (B): 282
Response Rate (A/B):
100%
Data Collection Instrument 6
Name of Data Collection Instrument:

Page 5 of 7

21-day fever and symptom follow-up form for contacts of probable or
confirmed Ebola patients
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Type of Respondent
General public
X Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Daily temperature and symptom checks for all contacts classified with high risk, some risk, and
no known exposure groups (higher risk, lower risk, and least risk)

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
X Other (describe):
Daily temperature and symptom checks for all contacts classified with
high risk, some risk, and no known exposure groups (higher risk,
lower risk, and least risk)
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
X Face-to-face Interview (describe):
By 10/14/14 all risk groups (high, some, and no known exposure)
were administered the questionnaires in person once daily and once
daily by telephone (active monitoring).
X Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
179
Total No. Sampled/Eligible to Respond (B): 179
Response Rate (A/B):
100%
(Additional Data Collection Instrument sections may be added if necessary.)

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
Page 6 of 7

Burden per
Response in
Minutes (C)

Total Burden
in Hours
(A x B x C)/60*

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Ebola Virus Disease Contact
Questionnaire
Ebola Virus Disease Contact
Questionnaire (Revised)
Ebola Virus Disease Case
Contact Questionnaire
(Initial)

Healthcare Worker
Interview Form
10/11/2014 (Interactions
since 30 September 2014)
Health Care worker
Supplemental Interview
Form

21-day fever and symptom
follow-up form for
contacts of probable or
confirmed Ebola patients

Close
community
contact
Close
community
contact
Healthcare
Worker
Contact
Health care
worker
contact

45

1

15 min

12 hrs

6

1

15 min

2 hrs

85

1

15 min

22 hrs

282

1

5 min

24 hrs

Health care
worker
contact
All high,
some, and
no-known
exposure
contact risk
groups

282

1

5 min

24 hours

179

1

5

15 hours

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 7 of 7

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

2015001-XXX
2015-001
Georgian National Centers for Disease Control and Public Health (NCDC)
Undetermined mode of transmission and risk factors for Crimean-Congo Hemorrhagic
Fever among Georgians - Tbilisi, Georgia, 2014

Purpose of Investigation: (Use Although Crimean-Congo Hemorrhagic Fever (CCHF) is known to be endemic in
as much space as necessary) Georgia since its discovery in 2009, the highest number of cases ever reported and

above surveillance baseline occurred this year. The purpose of the investigation
was to identify the extent of the current outbreak as well as the mode of
transmission and risk factors. The objectives of the investigation are as follows:
1. Review existing data to accomplish the following:
a.
Clarify case definitions of suspect, probable, and confirmed.
b.
Identify any recent modifications to the surveillance system including changes in
laboratory assays used.
c.
Describe the characteristics and clinical presentation of each case.
d.
Investigate and identify known risk factors for each case.
e.
Identify the laboratory testing, if any, performed for each case.
f.
Determine the mode of transmission of CCHF in these case-patients.
g.
Link existing animal, entomologic, and human epidemiologic and serologic data.
2: Conduct a field investigation to accomplish the following:
a.
Assess knowledge, attitudes, and practices (KAP) related to CCHF in the affected
regions to identify risk factors for infection.
b.
Identify cases of CCHF infection and determine the scope of the outbreak among
at-risk populations in the affected region.
Overall, the goal is to identify the mode of transmission and the risk factors for CCHF in
this outbreak to effectively implement public health interventions to mitigate future CCHF
risk and transmission.
Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

10/6/14
10/22/14
Ashley Greiner
CGH/DGHP/GDD

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
CCF_Knowledge, Attitudes and Practices (KAP) Survey
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Respondents of the field investigation will be residents of villages with at least one reported
CCHF case in 2014.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Field investigation was conducted in those regions with positive
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
case-patients in 2014 to identify risk factors for infection, identify
cases of CCHF infection, and describe the extent of the outbreak.
Households were randomly selected. The KAP survey was
administered to each selected household and a blood specimen
was collected.
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
A 10 ml whole blood sample was obtained and sent for CCHF
diagnostic testing. Serum was separated by centrifugation and
split into two aliquots. Testing was performed at Lugar
Laboratory for recent (within the past 2-4months) and past
(within past 5 years) CCHF infection by anti-CCHF IgM and IgG,
respectively. The samples will be stored for up to 2 years in
case repeat CCHF testing needs to be performed. Samples
may be processed at CDC Atlanta Laboratory if confirmation
testing is required.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Survey administered by face-to-face interview.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
A 10 ml whole blood sample was obtained and sent for CCHF
diagnostic testing. Serum was separated by centrifugation and
split into two aliquots. Testing was performed at Lugar Laboratory
for recent (within the past 2-4months) and past (within past 5
years) CCHF infection by anti-CCHF IgM and IgG, respectively.
The samples will be stored for up to 2 years in case repeat CCHF
testing needs to be performed. Samples may be processed at
CDC Atlanta Laboratory if confirmation testing is required.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
651
Total No. Sampled/Eligible to Respond (B): 658
Response Rate (A/B):
0.989
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
Page 2 of 4

CCHF_Case Investigation Questionnaire

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
General public
Other (describe):

Healthcare staff
2014 CCHF Case-Patients

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
A chart review was performed of all case-patients, including
the extraction of pertinent clinical information and
laboratory results from the NCDC electronic disease
surveillance system (EIDSS). Charts were reviewed be 1
federal employee.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample

Response Rate (if applicable)
Total No. Responded (A):
1
Total No. Sampled/Eligible to Respond (B): 1
Response Rate (A/B):
100%

Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Data Collection Instrument
Type of
Respondents
per Respondent
Name
Respondent
(A)
(B)
CCHF_KAP Survey
General
651
1
Public
CCHF_Case Investigation
Federal
1
22
Questionnaire
employee
Page 3 of 4

Burden per
Response in
Minutes (C)
30

Total Burden
in Hours
(A x B x C)/60*
325.5

5

1.83

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 4 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):

2015002-XXX
2015-03

Requesting entity (e.g.,
jurisdiction):
Title of Investigation:

Fairfax County Health Department
Commonwealth of Virginia Department of Health
Undetermined risk factors for suicide among youth, ages 10-24 — Fairfax County, VA,
2014
Purpose of Investigation: (Use Since October 1, 2014, there have been 3 suicides among high school students in the
as much space as necessary) 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:
· 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.
· 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.
In order 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 and focus groups with parents were conducted. These data will
be used to identify factors associated with youth suicide in Fairfax County and to inform
public health prevention strategies.
Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

November 12, 2014
November 21, 2014
Erica Spies
Division of Violence Prevention

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
Suicide_Interview Guide
Type of Respondent
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
General public
Other (describe):

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Interviews and focus group data will be used to identify schooland 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):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
18
Total No. Sampled/Eligible to Respond (B): 18
Response Rate (A/B):
100
Data Collection Instrument 2
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

Parent focus group guide

Healthcare staff

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Interviews and focus group data will be used to identify schooland community-level risk and protective factors associated with
youth suicide and suicide behaviors.
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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Focus groups with parents
Response Rate (if applicable)
Total No. Responded (A):
71
Total No. Sampled/Eligible to Respond (B): NA – denominator information not available
Response Rate (A/B):
NA – denominator information not available
Complete the following burden table. Each data collection instrument should be included as a separate row.
Burden Table (insert rows for additional respondent types if needed)
No.
No. Responses
Type of
Respondents
per Respondent
Data Collection Instrument
Name
Respondent
(A)
(B)
Suicide_Interview Guide
School
18
1
administrators
and guidance
counselors
Suicide_Focus Group Guide Parent
71
1

Burden per
Response in
Minutes (C)
60

Total Burden
in Hours
(A x B x C)/60*
18

90

107

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Page 3 of 4

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Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Office: 404.498.6389
[email protected]

Page 4 of 4

Form Updated: 9/4/2014