ACE investigation burden memo

Att 5 ACE Burden Memo ACE Invs.docx

Assessment of Chemical Exposures (ACE) Investigations

ACE investigation burden memo

OMB: 0923-0051

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Attachment 5 –Assessment of Chemical Exposures (ACE) Investigations Burden Memo (0923-0051)

Shape1


1. ACE Investigation GenIC No.:



2. Title of Investigation:



3. Chemical Incident


Investigated:







4. Date of Investigation:

Beginning:


End:


5. Name, CIO, and Contact Information of Lead Investigator:







Complete this section for each instrument used during the investigation.


Data Collection Method (check all that apply):

  • Questionnaire:

Face-to-face Interview

Telephone Interview

Self-administered Paper and Pencil

Self-administered Internet

  • Focus Group

  • Medical Chart Review

  • Hospital Survey

  • Laboratory Sample

  • Other (please specify):


Response Rate (if applicable):

Total No. Responded (A): ____________________

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

Response Rate (A/B): ____________________


Burden Table (insert rows for additional respondent types if needed)

Data Collection Instrument Name

Type of Respondent (e.g., general public, health care providers, responders, employees of the company)

Number of Respondents

(A)

Number of Responses per Respondent

(B)

Burden per Response (minutes)

(C)

Total Burden

(in minutes;

A x B x C)





















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleEmergency Epidemic Investigations
Authorlmp2
File Modified0000-00-00
File Created2021-01-21

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