Request for Approval Under the Generic Clearance for
Drug Overdose Response Investigation (DORI) Data Collection (OMB#: 0920-1054)
TITLE
LEAD INVESTIGATING OFFICER
Name:
Role and Office: (i.e. EIS Officer - CDC/NCIPC/DVP)
Email:
Ph:
CDC Sponsoring Program and Primary Contact Person:
Name:
Role and Office: (i.e. EIS Officer - CDC/NCIPC/DVP)
Email:
Ph:
INTRODUCTION
Describe the need and circumstances of the drug overdose response investigation.
Specify which circumstances justify the DORI:
Increased overdose severity (e.g., increase in fatal overdoses)
Occurrence of a rare or unknown cause of morbidity or mortality related to drug overdose (e.g., inclusion of rare substances, such as in the case of fentanyl-laced heroin)
Opportunity to identify new information, such as risk factors previously unassociated with drug overdose or a change in indicators of death (e.g., reports of changes in breathing function prior to death that could signal the need for intervention)
Occurrence among a particular population (e.g., children)
Public or political concern (e.g., state governor declaration of a public health emergency in a given state)
PURPOSE
Describe the objectives of the investigation, specify the state or local authority that requested the response and the type of CDC technical assistance requested. Describe the purpose of the data collection activities. Include and reference the letter of invitation
METHODS
Describe the proposed data collection methods.
Case Definition:
Study Population:
Variables:
Respondents:
Anticipated burden hours:
Data analysis plan:
RESULTS
Describe how results will be synthesized and reported to the requesting state or local health authority.
BURDEN ESTIMATE
Data Collection Instrument Name |
Type of Respondent |
Data Collection Mode |
No. Respondents (A) |
No. Responses per Respondent (B) |
Burden per Response in Minutes (C) |
Total Burden in Hours (A x B x C)/60* |
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Total |
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INVESTIGATIVE TEAM
List full investigative team, including CDC staff and state/local health authority staff.
CITATIONS
Provide references for works cited.
ATTACHMENTS
Provide the draft data collection forms to be used in the investigation; specify respondents for each form.
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | CDC User |
File Modified | 0000-00-00 |
File Created | 2021-01-21 |