Burden Memo

Attachment 3c –Assessment of Chemical Exposures (ACE) Investigations Burden Memo (0923-0051)

1. ACE Investigation GenIC No.:
2. Title of Investigation:
3. Acute Incident
Investigated:
4. Date of Investigation:	Beginning:
	End:
5. Name, CIO, and Contact Information of Lead Investigator:
Complete this section for each instrument used during the investigation. Data Collection Method (check all that apply): Questionnaire: □ Face-to-face Interview □ Telephone Interview □ Self-administered Paper and Pencil □ Self-administered Internet Focus Group Medical Chart Review Hospital Survey Laboratory Sample Other (please specify):

Response Rate (if applicable):

Total No. Responded (A): ____________________

Total No. Sampled/Eligible to Respond (B): ____________________

Response Rate (A/B): ____________________

Burden Table (insert rows for additional respondent types if needed)

Data Collection Instrument Name	Type of Respondent (e.g., general public, health care providers, responders, employees of the company)	Number of Respondents (A)	Number of Responses per Respondent (B)	Burden per Response (minutes) (C)	Total Burden (in minutes; A x B x C)