Burden Memo Template

Att. E. Drug Overdose Response Investigation (DORI) Burden Memo

Burden Memo for the Generic Clearance

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

GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g., jurisdiction)
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:

INTRODUCTION

Describe any need and circumstances of changes to the initial submitted DORI. In case of no changes specify no changes to initial DORI.

Complete the following for each instrument used during the investigation.

Data Collection Instrument 1

Name of Data Collection Instrument:

Type of Respondent

[ ] State and local government staff

[ ] State and local health department staff

[ ] Overdose victim

[ ] Overdose victim’s family/friends

[ ] General public

[ ] Member groups at heightened risk for injury

[ ] Health care providers/pharmacists/dispensers

[ ] Law enforcement personnel

[ ] EMS first responders)

[ ] Representatives of community organizations

[ ] Other: [describe]

Data Collection Methods (check all that apply)

[ ] Epidemiologic Study (indicate which type(s) below)

[ ] Descriptive Study (describe):

[ ] Cross-sectional Study (describe):

[ ] Cohort Study (describe):

[ ] Case-Control Study (describe):

[ ] Other (describe):

Data Collection Mode (check all that apply)

[ ] Survey Mode (indicate which mode(s) below):

[ ] Face-to-face Interview (describe):

[ ] Telephone Interview (describe):

[ ] Self-administered Paper-and-Pencil Questionnaire (describe):

[ ] Self-administered Internet Questionnaire (describe):

[ ] Other (describe):

[ ] Medical Record Abstraction (describe):

[ ] Other (describe):

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 IRB/OMB liaison (e-mail: [email protected]).