Burden Memo

Attachment 12. Burden Memo for Poison Center Collaborations for Public Health Emergencies

Attachment 12. Burden Memo for Poison Center Collaborations for Public Health Emergencies (OMB Control No. 0920-1166, expiration date 02/29/2020)

GenIC No:
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:

Complete the following for each instrument used during the investigation.

Data Collection Instrument 1

Name of Data Collection Instrument:

Type of Event (check all that apply)

[ ] Natural or man-made disaster

[ ] Contaminated food or water

[ ] New or existing consumer product

[ ] Emerging health threat

[ ] Other: [describe]

Poison Centers Involved in the Investigation (states included)

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 ICRL (e-mail: [email protected]).