Burden Memo

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation: (Use
as much space as necessary)

2020003-XXX
Chicago Department of Public Health
Investigation of SARS-CoV-2 transmission in a jail—Chicago, Illinois, 2020
Chicago Department of Public Health requested epidemiologic assistance to investigate
an outbreak of SARS-CoV-2 at a jail that has ~5000 detainees and ~1500 Dept of
Correction employees. The first case in a correctional officer at Cook County Jail was
reported March 12th and the first case in a detainee on March 18th. During March 12th
to April 28th, 596 cases have been identified in detainees, and 362 in staff. On April
15th, two CDC staff were deployed to assist Chicago Department of Public Health with
the outbreak.
During a COVID-19 outbreak investigation in another type of congregate setting (i.e., a
skilled nursing facility), over half of cases identified through facility-wide testing were
asymptomatic and likely contributed to transmission within the facility; symptom
screening alone may be inadequate to promptly identify and isolate case-patients.
Findings will inform how the virus is spread, including the extent of pre-symptomatic
and asymptomatic infection and potential role in transmission. Findings can inform
medical isolation and quarantine policies for congregate settings and the general public,
including the role of testing and symptom assessment.
This investigation aimed to assess transmission of SARS-CoV-2, the virus that causes
COVID-19, in a correctional facility. Specifically, the objectives were:
a. To estimate the prevalence of SARS-CoV-2 and/or COVID-19 infection in
dorms where a confirmed positive individual had been living.
b. To assess utility of repeat testing to capture additional asymptomatic
shedding among contacts from units where a confirmed positive individual
had been living.
c. To identify factors associated with transmission.
d. To investigate the extent of transmission during pre-symptomatic and
asymptomatic infection.
Public health implications: Implement additional prevention measures where needed and
protect populations who may be at increased risk of infection; inform medical isolation
and quarantine procedures, including the role of testing and symptom assessment in 1)
identifying case-patients who are asymptomatic or with atypical symptoms for medical
isolation, and 2) determining when to end quarantine to prevent the early return of casepatients who are asymptomatic or with atypical symptoms while contagious.
We worked with correctional/detention facility staff to identify units (i.e., housing unit or
dorm for detained/incarcerated persons) recently placed on quarantine due to
identification of a detainee confirmed positive for SARS-CoV-2 (i.e. index patient).
Upon identification of a unit being placed under quarantine, the investigation team, in
conjunction with the local health departments, and with the assistance of facility health
staff and other stakeholders (e.g., Department of Corrections (DOC) Sheriff’s
Department), approached all individuals housed on the unit to participate in this
investigation. This occurred in addition to ongoing infection control measures and public
health response activities already in place at the facility based on recommendations
provided by local health departments and according to CDC interim guidance for the
management of COVID-19 in correctional and detention facilities
(https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidancecorrectional-detention.html).

Page 1 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)

Duration of Data Collection:
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

This EEI GenIC received OMB approval for the following forms:
1. Facility assessment (Appendix 1), to assess facility and housing unit-level
activities, practices, and layout.
2. Survey Day 0 (Appendix 2). This form assesses symptoms, risk factors for
transmission, social distancing practices, use of personal protective equipment,
and cleaning processes. It was completed by consenting participants the same
day of testing on investigation day 0.
3. Survey Day 3-4 (Appendix 3). At a second point in time, day 3 or 4, testing for
SARS-CoV-2 will be performed again for a cohort of consenting persons who
had negative test results (PCR) at enrollment to detect any asymptomatic
individuals positive for SARS-CoV-2. Consenting persons were asked to
complete this brief symptom assessment. These individuals who tested positive
for SARS-CoV-2 were isolated and/or re-housed in accordance with current
practices at the facility.
4. Survey Day 14 (Appendix 4). At a third point in time, day 14, testing for SARSCoV-2 was performed for a cohort of consenting persons who remain in
quarantine (asymptomatic, negative PCR test results at day 3 or 4) to detect any
asymptomatic individuals positive for SARS-CoV-2. Consenting persons were
asked to complete this brief survey.
5. Illinois Department of Public Health Request for COVID-19/Respiratory Testing
form (Appendix 5). Specimen collection materials were provided by CDC. The
investigation team collected specimens from each participant at enrollment and
at pre-determined intervals following enrollment (e.g., day 3 or 4). Viral testing
by RT-PCR was completed at the participating state public health lab, local
healthcare facilities as coordinated by the local health department
21 days
May 1, 2020
May 21, 2020
CDC
Katie Curran
NCIRD / COVID Response / Epi Task Force / Epi Field Studies Team

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument: SARS-CoV-2 Correctional Facility Assessment V7 rev 5/11/2020
(Correctional Facility Transmission Investigation)
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Correctional/detention facility staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Survey was conducted among facility staff to assess dormitory
characteristics.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Page 2 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
A paper form was administered by CDC team in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
12
Total No. Sampled/Eligible to Respond (B): 12
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument: SARS-CoV-2 Cook County Questionnaire V24 rev 05/05/2020 (Correctional
Facility Transmission Investigation) Day 0/1 Form
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Describe demographics, medical conditions, smoking history,
symptoms, potential exposures, and protective behaviors.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Page 3 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT-PCR.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
193
Total No. Sampled/Eligible to Respond (B): 224
Response Rate (A/B):
86%
Data Collection Instrument 3
Name of Data Collection Instrument:

SARS-CoV-2 Cook County Questionnaire V24 rev 5/05/2020 (Correctional
Facility Transmission Investigation) Day 3/4 Form

Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection and tested SARS-CoV-2 negative during previous surveys.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Describe symptoms since Day 0 / last visit.
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT-PCR.
Page 4 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
91
Total No. Sampled/Eligible to Respond (B): 97
Response Rate (A/B):
94%
Data Collection Instrument 4
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

SARS-CoV-2 Cook County Questionnaire V24 rev 5/05/2020 (Correctional
Facility Transmission Investigation) Day 14 Form

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection and tested SARS-CoV-2 negative during previous surveys. Some detained persons
(n=16) who tested SARS-CoV-2 positive were offered a brief survey to assess symptoms after
specimen collection.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Describe symptoms in past 2 weeks.
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet Questionnaire
(describe):
Other (describe):
Medical Record Abstraction
(describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT-PCR.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Page 5 of 7

93
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):
Data Collection Instrument 5
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

111
84%

ILLINOIS DEPARTMENT OF PUBLIC HEALTH Request For COVID-19 /
Respiratory Testing

Healthcare staff
Laboratory staff
Patients
Restaurant staff
CDC team and laboratory staff completed the test request form for each specimen collected.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Specimen collection type, date, place, and identification numbers
required for requesting SARS-CoV-2 test.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (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
Form completed on paper, excel spreadsheet, or online form.
(describe):
Other (describe):
Medical Record Abstraction
(describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

273
273
100%

(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)
Page 6 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)

Data Collection
Instrument Name
SARS-CoV-2
Correctional Facility
Assessment V7 rev
5/11/2020 (Correctional
Facility Transmission
Investigation)
SARS-CoV-2 Cook
County Questionnaire
V24 rev 05/05/2020
(Correctional Facility
Transmission
Investigation) Day 0/1
Form
SARS-CoV-2 Cook
County Questionnaire
V24 rev 5/05/2020
(Correctional Facility
Transmission
Investigation) Day 3/4
Form
SARS-CoV-2 Cook
County Questionnaire
V24 rev 5/05/2020
(Correctional Facility
Transmission
Investigation) Day 14
Form
ILLINOIS
DEPARTMENT OF
PUBLIC HEALTH
Request For COVID-19 /
Respiratory Testing

No.
Respondents
(A)
12

No. Responses
per Respondent
(B)
1

Burden per
Response in
Minutes (C)
120

Total
Burden
in Hours
(A x B x
C)/60*
24

Incarcerated/detained
person (200)

193

1

60

193

Incarcerated/detained
person

91

1

60

91

Incarcerated/detained
person

93

1

60

93

Correctional/detention
facility staff

273

3

5

69

Type of Respondent
Correctional/detention
facility staff

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 7 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g.,
jurisdiction):
Title of Investigation:
Purpose of Investigation: (Use
as much space as necessary)

2020004-XXX
Louisiana Department of Health
Investigation of SARS-CoV-2 transmission in a jail—Louisiana, 2020
Louisiana Department of Health requested epidemiologic assistance to investigate an
outbreak of SARS-CoV-2 at a jail that has ~700 detainees. The first case in a detainee
reported April 9. Since the first case was detected, 35 cases have been identified in
detainees, and 6 in staff.
During a COVID-19 outbreak investigation in another type of congregate setting (i.e., a
skilled nursing facility), over half of cases identified through facility-wide testing were
asymptomatic and likely contributed to transmission within the facility; symptom
screening alone may be inadequate to promptly identify and isolate case-patients. Findings
will inform how the virus is spread, including the extent of pre-symptomatic and
asymptomatic infection and potential role in transmission. Findings can inform medical
isolation and quarantine policies for congregate settings and the general public, including
the role of testing and symptom assessment.
This investigation aimed to assess transmission of SARS-CoV-2, the virus that causes
COVID-19, in a correctional facility. Specifically, the objectives were:
a. To estimate the prevalence of SARS-CoV-2 and/or COVID-19 infection in
dorms where a confirmed positive individual had been living.
b. To assess utility of repeat testing to capture additional asymptomatic shedding
among contacts from units where a confirmed positive individual had been
living.
c. To identify factors associated with transmission.
d. To investigate the extent of transmission during pre-symptomatic and
asymptomatic infection.
Public health implications: Implement additional prevention measures where needed and
protect populations who may be at increased risk of infection; inform medical isolation
and quarantine procedures, including the role of testing and symptom assessment in 1)
identifying case-patients who are asymptomatic or with atypical symptoms for medical
isolation, and 2) determining when to end quarantine to prevent the early return of casepatients who are asymptomatic or with atypical symptoms while contagious.
We worked with correctional/detention facility staff to identify units (i.e., housing unit or
dorm for detained/incarcerated persons) recently placed on quarantine due to
identification of a detainee confirmed positive for SARS-CoV-2 (i.e. index patient). Upon
identification of a unit being placed under quarantine, the investigation team, in
conjunction with the local health departments, and with the assistance of facility health
staff and other stakeholders (e.g., Department of Corrections (DOC) Sheriff’s
Department), approached all individuals housed on the unit to participate in this
investigation. This occurred in addition to ongoing infection control measures and public
health response activities already in place at the facility based on recommendations
provided by local health departments and according to CDC interim guidance for the
management of COVID-19 in correctional and detention facilities
(https://www.cdc.gov/coronavirus/2019-ncov/community/correction-detention/guidancecorrectional-detention.html).

Duration of Data Collection:
Date Began:
Page 1 of 7

28 days
May 7, 2020
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:

June 3, 2020
CDC
Katie Curran
NCIRD / COVID Response / Epi Task Force / Epi Field Studies Team

Complete the following for each instrument used during the investigation.
Data Collection Instrument 1
Name of Data Collection Instrument:
SARS-CoV-2 Correctional Facility Assessment
V3
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Correctional/detention facility staff

Patients

Restaurant staff

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Survey was conducted among facility staff to assess dormitory
characteristics.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
A paper form was administered by CDC team in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
6
Total No. Sampled/Eligible to Respond (B): 6
Response Rate (A/B):
100%
Data Collection Instrument 2
Name of Data Collection Instrument:
Page 2 of 7

SARS-CoV-2 Louisiana Questionnaire V3 (Correctional Facility Transmission
Investigation) Day 0/1 Form
Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Describe demographics, medical conditions, smoking history,
symptoms, potential exposures, and protective behaviors.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT143-PCR.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
143
Total No. Sampled/Eligible to Respond (B): 143
Response Rate (A/B):
100%
Data Collection Instrument 3
Name of Data Collection Instrument:

SARS-CoV-2 Louisiana Questionnaire V1 (Correctional Facility Transmission
Investigation) Day 3/4 Form

Type of Respondent
General public
Other (describe):

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection.

Data Collection Methods (check all that apply)
Page 3 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Describe symptoms since Day 0 / last visit.
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.
Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet
Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT-PCR.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
44
Total No. Sampled/Eligible to Respond (B): 45
Response Rate (A/B):
98%
Data Collection Instrument 4
Name of Data Collection Instrument:
Type of Respondent
General public
Other (describe):

SARS-CoV-2 Louisiana Questionnaire V1 (Correctional Facility Transmission
Investigation) Day 14 Form

Healthcare staff
Laboratory staff
Patients
Restaurant staff
Persons detained who were in quarantine after close contact with a person with SARS-CoV-2
infection.

Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Describe symptoms in past 2 weeks.
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Page 4 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Laboratory Testing (describe):

Nasopharyngeal specimens collected and tested for SARS-CoV-2
using RT-PCR.

Other (describe):
Data Collection Mode (check all that apply)
Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
CDC team conducted paper survey in person.
Telephone Interview (describe):
Self-administered Paper-and-Pencil
Questionnaire (describe):
Self-administered Internet Questionnaire
(describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Nasopharyngeal specimens were collected for SARS-CoV-2 testing by
RT-PCR.
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

186
186
100%

Data Collection Instrument 5
Name of Data Collection Instrument:
COVID-19 Test Request Form
Type of Respondent
General public
Healthcare staff
Laboratory staff
Patients
Restaurant staff
Other (describe): CDC team and laboratory staff completed the test request form for each specimen collected.
Data Collection Methods (check all that apply)
Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Specimen collection type, date, place, and identification numbers
required for requesting SARS-CoV-2 test.
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (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):
Page 5 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Self-administered Internet Questionnaire
(describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):
Response Rate (if applicable)
Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

Form completed on paper, excel spreadsheet, or online form.

373
373
100%

(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
SARS-CoV-2
Correctional Facility
Assessment V3
SARS-CoV-2 Louisiana
Questionnaire V3 Day 0/1
Form
(Correctional Facility
Transmission
Investigation)
SARS-CoV-2 Louisiana
Questionnaire V1
(Correctional Facility
Transmission
Investigation) Day 3/4
Form
SARS-CoV-2 Louisiana
Questionnaire V1
(Correctional Facility
Transmission
Investigation) Day 14
Form
COVID-19 Test Request
Form

No.
Respondents
(A)
6

No. Responses
per Respondent
(B)
1

Burden per
Response in
Minutes (C)
120

Total Burden
in Hours
(A x B x
C)/60*
144

Incarcerated/detained
person

143

1

60

143

Incarcerated/detained
person

44

1

60

44

Incarcerated/detained
person

186

1

60

186

Correctional/detention
facility staff

373

3

5

94

Type of Respondent
Correctional/detention
facility staff

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection
completion to the EEI Information Collection Request Liaison, Danice Eaton ([email protected]).
EEI Information Collection Request Liaison:
Page 6 of 7

Form Updated: 9/4/2014

Burden Memo for the Generic Clearance of Emergency Epidemic Investigation Data Collections
(0920-1011)
Danice Eaton, PhD, MPH
EIS Program Staff Epidemiologist
Epidemiology Workforce Branch
Division of Scientific Education and Professional Development
Centers for Disease Control and Prevention
2400 Century Center, MS E-92
Office: 404.498.6389
[email protected]

Page 7 of 7

Form Updated: 9/4/2014