Burden Memo

Drug Overdose Response Investigation (DORI) Burden Memo

Attachment D

Form Approved

OMB No: 0920-xxxx
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-xxxx).

Burden Memo

Public Health/Public Safety Strategies to Reduce Drug Overdose Data Collection

(OMB#: 0920-XXXX)

GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g., jurisdiction and agency)
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 PH/PS Strategies Data Collection. In case of no changes specify no changes to initial request.

Complete the following for each instrument used during the investigation.

Data Collection Instrument 1

Name of Data Collection Instrument:

Type of Participant (check all the apply)

• Public health professionals

• Public safety professionals (i.e. police officers, correctional staff, emergency medical personnel, fire and rescue)

• Medical examiners

• Individuals served by policies or programs to reduce overdose

• Individuals who use drugs or have a history of drug use or criminal-legal involvement

• Families and friends of individuals who use drugs or have a history of drug use or criminal legal involvement

• Health care providers, including substance use service providers

• Pharmacists

• Representatives of harm reduction, peer recovery drug prevention or other community organizations

• Other: [describe]

Data Collection Mode (check all that apply)

• Survey Mode (indicate which mode(s) below):

• Web-based

• Self-administered, in person

• Investigator-administered, in person

• Interview Mode (indicate which mode(s) below):

• Face-to-face

• Remote

• Observation (describe):

• Document or record review (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 Participant	No. Participant (A)	No. Responses per Participant (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 IRB/OMB liaison (e-mail: [email protected]).