DORI Request Template

Drug Overdose Response Investigation Protocol Template: Attachment D

Request for Approval Under the Generic Clearance for

Drug Overdose Response Investigation (DORI) Data Collection (OMB#: 0920-1054)

Drug Overdose Response Investigation Protocol Template

TITLE

LEAD INVESTIGATING OFFICER

Name:

Role and Office: (i.e. EIS Officer - CDC/NCIPC/DVP)

Email:

Ph:

CDC Sponsoring Program and Primary Contact Person:

Name:

Role and Office: (i.e. EIS Officer - CDC/NCIPC/DVP)

Email:

Ph:

INTRODUCTION

Describe the need and circumstances of the drug overdose response investigation.

Specify which circumstances justify the DORI:

• Increased overdose severity (e.g., increase in fatal overdoses)

• Occurrence of a rare or unknown cause of morbidity or mortality related to drug overdose (e.g., inclusion of rare substances, such as in the case of fentanyl-laced heroin)

• Opportunity to identify new information, such as risk factors previously unassociated with drug overdose or a change in indicators of death (e.g., reports of changes in breathing function prior to death that could signal the need for intervention)

• Occurrence among a particular population (e.g., children)

• Public or political concern (e.g., state governor declaration of a public health emergency in a given state)

PURPOSE

Describe the objectives of the investigation, specify the state or local authority that requested the response and the type of CDC technical assistance requested. Describe the purpose of the data collection activities. Include and reference the letter of invitation

METHODS

Describe the proposed data collection methods.

Case Definition:

Study Population:

Variables:

Respondents:

Anticipated burden hours:

Data analysis plan:

­­­­­­­­­­­­­­­­­­­­­­­­

RESULTS

Describe how results will be synthesized and reported to the requesting state or local health authority.

BURDEN ESTIMATE

Data Collection Instrument Name	Type of Respondent	Data Collection Mode	No. Respondents (A)	No. Responses per Respondent (B)	Burden per Response in Minutes (C)	Total Burden in Hours (A x B x C)/60*
					Total

INVESTIGATIVE TEAM

List full investigative team, including CDC staff and state/local health authority staff.

CITATIONS

Provide references for works cited. 

ATTACHMENTS

Provide the draft data collection forms to be used in the investigation; specify respondents for each form.