Form 0923-0047 Traceable Opioid Material* Kit Questions

Attachment 2. Traceable Opioid Material* Kits Questions

Form Approved
OMB No. 0923-0047
Exp. Date 01/31/2022

Traceable Opioid Material* Kit Questions
Please provide the information below so that your request can be processed quickly.
1. Which of the following best describes your laboratory? (Select only one)
 Academic Research Laboratory
 Environmental Laboratory
 Government Crime Laboratory
 Government Toxicology Laboratory
 Private or Public Clinical Laboratory
 Other (please specify) _____________________________________
2. Which of the following tests or services are performed by your laboratory? (Select all that apply)
 Seized drug sample testing
 Post-mortem toxicology sample testing
 Workplace drug screening
 Newborn drug screening
 Drug pharmacology and pharmacokinetics research
 Clinical testing for disease diagnosis and treatment or surveillance
 Other __________________________________________________
3. On average, how many opioid-related samples does your laboratory analyze on a weekly basis?
 <100
 101-500
 501-1000
 >1000
--------------------------------------------------------------------------------------------------------------------------4. Which of the following analytical techniques do you perform in your laboratory?
(Select all that apply)
 Immunoassay
 Infrared Spectroscopy
 Mass Spectrometry
 Nuclear Magnetic Resonance Spectroscopy
 Raman Spectroscopy
 X-ray Diffraction
 Chromatographic Separation
 UV/Vis
 Other (please specify) _____________________________________
5. Which matrix type does your laboratory analyze? (Select all that apply)
 Blood
 Urine
 Other (please specify) _____________________________________
6. What sample sizes are being tested? (Select all that apply)
 <0.1 mL
 0.1- 0.5 mL
 >0.5 mL
 Other (please specify) _____________________________________
*TRACEABLE OPIOID MATERIAL, TOM KITS, and the TOM KITS logo are marks of the U.S. Department of Health and Human Services.
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instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and
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information unless it displays a currently valid OMB Control Number. Send comments regarding this burden estimate or any other aspect of this
collection of information, including suggestions for reducing this burden to CDC/ATSDR Information Collection Review Office, 1600 Clifton Road
NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-0047).