Five Year Distribution Full Scale Exercise, or Incident

Form Approved

OMB Approval No. 0920-xxxx

Expiration Date: xx/xx/xxxx

Five Year Distribution – Full Scale Exercise

Distribution FSE, or incident

a. Start date and time

b. End date and time

c. RSS facility setup (yes or no)

i. RSS facility staff participating

ii. RSS security participating

d. Number of sites receiving MCMs (include any RDS/LDS, open PODs, closed PODs, healthcare)

e. Number and type of transportation assets mobilized

f. Backup transportation used (yes or no), if yes, describe inject used to activate back-up transport, or situation requiring use of backup transport during an incident

g. Procedures for cold chain management (yes or no), if yes, describe how cold chain management was exercised or used

h. Security plans were demonstrated in the following distribution phases (select all that apply)

i. Request for federal assets

j. RSS facility estimate of warehouse processing time

k. Total time for distribution (from RSS site to local site)

Public reporting burden of this collection of information is estimated to average 120 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).