Burden Memo

AttachH_Burden Memo.docx

California Drought - Mariposa County, 2016 (Quarter 4)

Burden Memo

OMB: 0920-1036

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Attachment H. Burden Memo



CDC DOCUMENTATION FOR THE GENERIC CLEARANCE

OF COMMUNITY ASSESSMENT FOR PUBLIC HEALTH EMERGENCY RESPONSE (CASPER) DATA COLLECTIONS (0920-XXXX)

Shape1


GenIC No.:


CASPER Title:


Requesting entity (e.g., jurisdiction)


Purpose of Investigation: (Use as much space as necessary)



Duration of Data Collection


Date Began:


Date Ended:


Lead Investigator


Name:


CIO/Division/Branch:


E-mail Address:


Telephone No.:


Mail Stop:




Complete the following for each instrument used during the investigation.


CASPER Questionnaire


Title:



Data Collection Methods (i.e., was the standard CASPER methodology of probability-based, two stage 30x7 cluster sampling methodology used or was an alternative approved methodology used? Please describe.):


Data Collection Mode (i.e., was questionnaire data collected via paper form or electronic form? Please describe.):


Response Rate (if applicable)

Total No. Responded (A):


Total No. Sampled or Eligible to Respond (B):


Response Rate (A/B):





CASPER Referral Form


Title:


Response Rate (if applicable)

Total No. Responded (A):


Total No. Sampled or Eligible to Respond (B):


Response Rate (A/B):



Complete the following burden table. Each data collection instrument should be included as a separate row.


Burden Table

Data Collection Instrument Name

Type of Respondent

No. Respondents (A)

No. Responses per Respondent (B)

Burden per Response in Minutes (C)

Total Burden

(in minutes;

A x B x C)

CASPER Questionnaire






CASPER Referral Form













Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection completion to the ICRL (e-mail: [email protected]; MS F-61). If data was collected electronically, please also submit screen shots.



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