Form 0920- Investigation Protocol Template

Drug Overdose Response Investigation Protocol Template

Attachment C

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).

Investigation Protocol Template

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

(OMB#: 0920-XXXX)

Request Title:

Lead Investigator:

Name:

Role and Agency: (i.e. Epidemiologist, CDC/NCIPC/DOP)

Email:

Phone:

CDC Sponsoring Program and Primary Contact Person:

Name:

Role and Office: (i.e. Branch Chief - CDC/NCIPC/DOP)

Email:

Phone:

INTRODUCTION

Describe the need and circumstances of the drug overdose response investigation.

Specify which circumstances justify the PH/PS Strategies investigation:

• Increased overdoses (e.g., increase in number of nonfatal or fatal overdoses or accelerating trends) among justice-involved populations

• Emergence of a new overdose prevention or response strategy or expansion of an existing PH/PS strategy

• Indication that a promising or evidence-based strategy has not been widely adopted, is not meeting its intended goals, or is not reaching all populations equitably

• Other (Describe)

PURPOSE

Describe the objectives of the investigation, specify the state or local authority(ies) that requested the response and the type of CDC technical assistance requested. Describe the strategy(ies) to be investigated. Include and reference the letter of invitation.

METHODS

Describe the proposed data collection methods.

Types of participants:

Data collection procedures:

Variables and measures to be collected:

Anticipated number of participants:

Anticipated burden hours (see table below):

Data analysis plan:

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RESULTS

Describe how results will be synthesized and reported to the requesting state or local health authority. Describe how results will be used.

BURDEN ESTIMATE

Data Collection Instrument Name	Type of Participant	Data Collection Mode	No. Respondents (A)	No. Responses per Participant (B)	Burden per Response in Minutes (C)	Total Burden in Hours (A x B x C)/60*
					Total

INVESTIGATIVE TEAM

List full investigative team, including CDC staff and state/local health agency staff.

CITATIONS

Provide references for works cited. 

ATTACHMENTS

Provide the draft data collection forms to be used in the investigation; specify respondents for each form.