Burden Memo Y2Q1

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)

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

0920-1101
2015-023
Mississippi State Department of Health
Adverse Health Effects Associated with Synthetic Cannabinoid Use
Since April 2, 2015, Mississippi Department of Health noticed an increase in the number
of adverse health events associated with synthetic cannabinoid use. The Mississippi
Department of Health requested the assistance of the National Center for Environmental
Health to better characterize the outbreak, identify risk factors for severe illness and
death, and prevent further illness. CDC staff assisted Department of Health staff;
activities included case finding, medical record abstractions, patient interviews, and data
analysis.
4/28/15-5/7/15
4/28/15
5/7/15
Amelia Kasper
NCEH/DEHHE/HSB

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument: Patient Interview 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):
Questionnaire-based inquiry of why patients used synthetic
cannabinoids, what health effects they experienced, and what
might be effective messaging from the Mississippi State
Department of Health regarding use of synthetic cannabinoids.
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):
Mississippi State Department of Health staff used the tool to
conduct in person interviews with suspect case-patients in the
emergency department of University of Mississippi Medical Center.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
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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):
Response Rate (if applicable)
Total No. Responded (A):
4
Total No. Sampled/Eligible to Respond (B): 5
Response Rate (A/B):
0.8
Data Collection Instrument 2
Name of Data Collection Instrument: Chart Abstraction Form
Type of Respondent
General public
Other (describe):

Healthcare staff
Medical records only

Laboratory staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Collected data to describe patient population and disease course
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): Vital signs, physical examination, clinical narrative, laboratory data,
EMS reports, and poison control center reports.
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
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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): 119
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)
Patient interview form
Patients
4
1
Chart Abstraction form
Federal
6
n/a
Employees

Burden per
Response in
Minutes (C)
30
n/a

Total Burden
in Hours
(A x B x C)/60*
2
n/a

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]

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Form Updated: 9/4/2014