MDN for Case Data Form Template

Attachment 5. Minimal Data Necessary for Case Data During an Emergency Response Form

REQUEST FOR APPROVAL UNDER THE GENERIC CLEARANCE FOR THE COLLECTION OF MINIMAL DATA NECESSARY FOR CASE DATA DURING AN EMERGENCY RESPONSE (0920-XXXX)

This form should be completed by the primary contact person for the emergency response.

DETERMINE IF THE DATA COLLECTION IS APPROPRIATE FOR THIS GENERIC CLEARANCE MECHANISM: Before completing and submitting this form, determine first if the proposed data collection is appropriate for the MDN for Case Data Generic ICR mechanism. Complete the checklist below. If you select “yes” to the criterion in Column A, the MDN Generic ICR mechanism can be used. If you select “yes” to the criterion in Column B, the MDN Generic ICR mechanism cannot be used.

Column A	Column B
Public harm is reasonably likely to result if normal clearance procedures are followed. [ ] Yes [ ] No	Public harm is not reasonably likely to result if normal clearance procedures are followed. [ ] Yes [ ] No
An emergency has occurred. [ ] Yes [ ] No	An emergency has not occurred. [ ] Yes [ ] No
The use of normal clearance procedures is reasonably likely to prevent or disrupt the collection of information. [ ] Yes [ ] No	The use of normal clearance procedures is not reasonably likely to prevent or disrupt the collection of information. [ ] Yes [ ] No
Case data will be collected for a disease or condition that is the subject of an emergency response at CDC. [ ] Yes [ ] No	Case data will be collected for a disease or condition that is not the subject of an emergency response at CDC. [ ] Yes [ ] No

Did you select “Yes” to the criterion in Column A?

If yes, the MDN Generic ICR may be appropriate for your data collection. → You may proceed with this form.

Did you select “Yes” to the criterion in Column B?

If yes, the MDN Generic ICR is not appropriate for your data collection. → Stop completing this form now.

TIMING OF OMB APPROVAL FOR THIS DATA COLLECTION: Indicate the approval time that OMB agreed to for this information collection.

[ ] 72 hours

[ ] 4 days

[ ] 5 days

ESTIMATION OF LENGTH OF APPROVAL: Estimate the duration of this information collection.

TITLE OF EMERGENCY RESPONSE:

DESCRIPTION:

1. Description of the emergency response:

Include all information known at this time about the emergency response including background information that is necessary to understand the importance of the emergency response, a description of the disease or condition that is the subject of the emergency response, what prompted CDC to respond to the emergency, and how case data will be used.

2. Is the disease or condition that is the subject of the emergency response a nationally notifiable condition or a condition under standardized surveillance?

[ ] Yes [ ] No, CDC requests permission to collect GenV2 data elements

3. How is this information collection essential to the mission of the agency?

RESPONSE-SPECIFIC DATA ELEMENTS TO BE COLLECTED:

In the table below or on an attached spreadsheet, list each response-specific data element, its definition, and its value set. Include the precedent for using the definition and value set, including whether the definition and value set are currently used for routine surveillance (e.g., definition and value set used for routine influenza surveillance) and the situation or event where the definition and value set were used in the past (e.g., definition used during the COVID-19 response; value set used in the United States Core Data for Interoperability (USCDI)). Include dates of use. Include an overall justification for using the data element and include what information and insight it will provide that is not already provided. Note that the definition and value set precedent and overall justification can apply to more than one data element.

Name	Definition	Value Set	Definition and Value Set Precedent	Overall Justification

BURDEN TABLE

The burden table below is the standard burden table that is used for each GenIC under the MDN Generic ICR. This burden table estimates the burden incurred by states, territories, freely associated states, and cities to submit case data to CDC daily. The burden table does not need to be modified and will accommodate all condition(s) and data element(s) that are specified on this form.

Type of Respondent	Form Name	Number of Respondents	Number of Responses per Respondent	Average Burden per Response (in hours)	Total Burden (in hours)
States	Submission of case data	50	365	30/60	9,125
Territories	Submission of case data	5	365	30/60	913
Freely Associated States	Submission of case data	3	365	30/60	548
Cities	Submission of case data	2	365	30/60	365
Total					10,951

EMERGENCY RESPONSE LEAD: Indicate the name, title, and Affiliation (CIO, Division, and Branch) of the person who will be leading the emergency response.

Name:

Title:

Affiliation:

CERTIFICATION: Please read the certification carefully. Type your name to validate that you are providing certification. Note: If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Certification should be signed by the Emergency Response Lead.

I, [INSERT NAME OF EMERGENCY RESPONSE LEAD], certify the following to be true:

1. The collection is voluntary.

2. Information gathered will be primarily used to provide situational awareness at the federal level to support decision making, particularly for public health threats that escalate quickly and cross jurisdictions.

3. The MDN, GenV2, and response-specific data elements (if applicable) will be collected for the duration of the response.

4. A final and complete Response-Specific Data Elements Form will be submitted within 30 days of the conclusion of the response. The form will include a complete list of response-specific data elements that were collected during the response including those that were not listed on this initial request form.

Emergency Response Lead Name:

Date of Certification:

REQUESTED APPROVAL DATE (MM/DD/YYYY): Instruction: Indicate the date by which approval is needed. This date must be in the timeframe (between 72 hours and 5 days) that was previously agreed to with OMB

DATE SUBMITTED TO INFORMATION COLLECTION REQUEST LIAISON (MM/DD/YYYY): Instruction: Please indicate the date the request is submitted to the ICRL.

E-mail the completed form to the Information Collection Request Liaison (ICRL), FIRST LAST, at [email protected]. If submitting outside business hours and immediate approval is needed, call XXX-XXX-XXXX to notify the ICRL of the submission.

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