Burden Memo Template

Att. E Burden Memo Gen 1054 DORI.docx

Drug Overdose Response Investigation (DORI) Data Collections

Burden Memo Template

OMB: 0920-1054

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Att. E. Drug Overdose Response Investigation (DORI) Burden Memo


Burden Memo for the Generic Clearance

Drug Overdose Response Investigation (DORI) Data Collection (OMB#: 0920-1054)


Shape1


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:


E-mail Address:


Telephone No.:


Mail Stop:




INTRODUCTION


Describe any need and circumstances of changes to the initial submitted DORI. In case of no changes specify no changes to initial DORI.


Complete the following for each instrument used during the investigation.


Data Collection Instrument 1


Name of Data Collection Instrument:


Type of Respondent

[ ] State and local government staff

[ ] State and local health department staff

[ ] Overdose victim

[ ] Overdose victim’s family/friends

[ ] General public

[ ] Member groups at heightened risk for injury

[ ] Health care providers/pharmacists/dispensers

[ ] Law enforcement personnel

[ ] EMS first responders)

[ ] Representatives of community organizations

[ ] Other: [describe]


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):


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):

[ ] Other (describe):


Response Rate (if applicable)

Total No. Responded (A):


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


Response Rate (A/B):



(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

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)




















Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection completion to the
IRB/OMB liaison (e-mail: [email protected]).


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