0920-1011 - EEI GenIC - Burden Estimate

Burden Estimate for the Generic Clearance of Emergency Epidemic Investigation Data Collections

(0920-1011)

GenIC No.:	20220001-XXX
Title of Investigation:	Undetermined risk factor for highly pathogenic avian influenza H5N1 among individuals exposed to infected birds – United States, 2022

For each data collection instrument included with the GenIC, estimate the burden by completing the table below. 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	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*
Aggregate counts of persons exposed to HPAI	Public Health Official	Electronic form	50	12	10	100 hours
HPAI H5 Consent Form	Public Health Official	Face-to-face interview	100	1	10	17 hours
HPAI H5 Consent Form (Spanish)	Public Health Official	Face-to-face interview	50	1	10	8 hours
Avian Influenza Initial Case Investigation Form	Public Health Official	Face-to-face interview	50	1	10	8 hours
Avian Influenza Initial Case Investigation Form (Spanish)	Public Health Official	Face-to-face interview	50	1	10	8 hours
Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire	Public Health Official	Face-to-face interview	100	1	10	17 hours
Highly Pathogenic Avian Influenza A (H5N1) Exposure Questionnaire (Spanish)	Public Health Official	Face-to-face interview	50	1	10	8 hours
HPAI H5 Self Swab Instructions	General Public	Lab test	50	1	10	8 hours
HPAI H5 Self Swab Instructions (Spanish)	General Public	Lab test	50	1	10	8 hours
Human Sera Collection Guidelines for Flu Serology	Public Health Official	Lab test	100	1	10	17 hours

*Round up to the nearest whole number.

Return completed form with the GenIC request to EEI Information Collection Request Liaison or EIS program designee.

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 2 of 2 Form Updated: 5/29/2014