Form 0920-20JE TOM Kits Questions

Attachment 6. Traceable Opioid Material* Kits Questions & Examples

NOTE: OMB Control Number will be updated upon approval

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. 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) 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 On average, how many opioid-related samples does your laboratory analyze on a weekly basis?  <100  101-500  501-1000  >1000 --------------------------------------------------------------------------------------------------------------------------- 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) Which matrix type does your laboratory analyze? (Select all that apply) Blood Urine Other (please specify) 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. CDC estimates the average public reporting burden for this collection of information as 6 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information needed, and completing and reviewing the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a collection of 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).