Att. D Burden Memo Generic Suicide_30 day

Attachment D

Form Approved

OMB No: 0920-1243
Exp. Date: xx/xx/xxxx

Public Reporting burden of this collection of information is estimated at X 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-1243).

Burden Memo for the Generic Clearance

Rapid Response Suicide Investigation Data Collection

GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g., jurisdiction)
Title of Investigation:
Purpose of Investigation: (Use as much space as necessary)
Duration of Data Collection
Date Began:
Date Ended:
Lead Investigator
Name:
CIO/Division/Branch:
E-mail Address:
Telephone No.:
Mail Stop:

INTRODUCTION

Describe any need and circumstances of changes to the initial submitted GenIC. In case of no changes specify no changes to initial GenIC.

Complete the following for each instrument used during the investigation.

Data Collection Instrument 1

Name of Data Collection Instrument:

Type of Respondent

[ ] Public health authorities

[ ] Medical examiners

[ ] Coroners

[ ] Hospital providers

[ ] Community health care providers

[ ] School personnel

[ ] Individuals who engage in nonfatal suicidal behavior

[ ] Family members of individuals who engage in nonfatal suicidal behavior

[ ] Friends of individuals who engage in nonfatal suicidal behavior

[ ] Emergency Medical Services personnel

[ ] Representatives of community organizations that provide information or support to the identified

geographic location or vulnerable population

[ ] Other: [describe]

Data Collection Methods (check all that apply)

[ ] Epidemiologic investigation (indicate which type(s) below)

[ ] Descriptive (describe):

[ ] Cross-sectional (describe):

[ ] Cohort (describe):

[ ] Case-control (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):

[ ] Web-based questionnaire (describe):

[ ] Self-administered questionnaire (describe):

[ ] Focus group (describe):

[ ] Other (describe):

[ ] Archival record abstraction (describe):

[ ] Other (describe):

Response Rate (if applicable)

Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

(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	Type of Respondent	No. Respondents (A)	No. Responses per Respondent (B)	Burden per Response in Minutes (C)	Total Burden (in minutes; A x B x C)

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection completion to the Rapid Response Suicide Investigation Data Collection Information Collection Request Coordinator (e-mail: [email protected]).