Burden Memo

Attachment H. Burden Memo

CDC DOCUMENTATION FOR THE GENERIC CLEARANCE

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

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.