Jurisdictional Data Sheet

Form Approved

OMB Approval No. 0920-xxxx

Expiration Date: 0x/xx/2021

Jurisdictional Data Sheet

Jurisdiction population

Number of county, city, tribal, and local health departments

Number of county, city, tribal, and local health departments required to develop local mass prophylaxis plans

Total sites that receive materiel directly from the RSS

Closed POD section

Jurisdiction dispenses prophylaxes directly to public health responders or critical infrastructure personnel (CIP)

Jurisdiction administers vaccine directly to public health responders or critical infrastructure personnel (CIP)

Population served by CPODs

Number of CPODs

Number of CPODs exercised

Number of agreements in place with dispensing sites using alternate dispensing methods

Total number of designated primary open (public) PODs

Population to be covered by open PODs

Open PODs: total population per hour to process

Roll-up: Current number of open PODs

Number of open PODs exercised

Public reporting burden of this collection of information is estimated to average 150 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 (0920-xxxx).