Form 0920-0980 Registration Form

Form Approved

OMB No. 0920-0980 Exp. Date 08/31/2022

CDC estimates the average public reporting burden for this collection of information as 10 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-0980)

CDC National Environmental Assessment Reporting System (NEARS)

Notice of Participation

Name of Agency/Program: ________________________________________________

This document serves as an acknowledgement of participation of the aforementioned agency/program in the National Environmental Assessment Reporting System (NEARS) of the National Center for Environmental Health, Centers for Disease Control and Prevention (CDC).

NEARS is a surveillance program through the Centers for Disease Control and Prevention’s (CDC) National Center for Environmental Health to capture environmental causes of foodborne illness outbreaks. Since April 2014, agencies/programs participating in NEARS have been reporting their foodborne illness outbreak environmental assessment data to NEARS.

Information collected through NEARS will be used to

• Identify and monitor outbreak contributing factors and their environmental antecedents,

• Provide a basis for hypothesis generation regarding factors that may contribute to foodborne outbreaks, and

• Guide planning, implementation, and evaluation of food safety programs.

NEARS data collectors will

• Be knowledgeable and familiar with outbreak investigation(s) entered into NEARS,

• Collaboratively work with epidemiological and laboratory agencies/programs to collect applicable outbreak data.

NEARS data collectors or other persons assigned by the agency are responsible for entering the environmental assessment related into NEARS.

NEARS data collectors are encouraged to complete CDC’s free e-Learning on Environmental Assessment of Foodborne Illness Outbreaks.

NEARS Group Administrator

The agency/program must identify one NEARS group administrator who will be responsible for the following:

• Creating NEARS accounts for all their data collectors

• Monitoring, verifying, and approving all data entered into NEARS for the agency/program

• Serving as the NEARS group point of contact (POC) for CDC.

NEARS group administrators are encouraged to complete CDC’s free e-Learning on Environmental Assessment of Foodborne Illness Outbreaks.

Note:

The agency/program must inform CDC in writing if the NEARS group administrator or any data collector(s) no longer need access to NEARS within 3 business days of the event. Additionally, all NEARS users must notify CDC of lost or compromised passwords immediately.

Please sign below:

As the NEARS Group Administrator of the aforementioned agency/program, I understand that our agency/program is responsible for the accuracy of data submitted and entered into NEARS. In addition, data entered into NEARS can be used at the discretion of CDC. However, data requests made outside of the participating agency/program (other federal, state, and local agencies, academia, etc.) can be shared upon my agency’s written consent.

Printed Name of the NEARS Group Administrator: _________________________________

Title: _____________________________

Agency/Program: __________________________________

Signature: ________________________________________

Date: _______________________

Submit the completed document by email to [email protected]

Page 2 of 2