Att3c Burden Memo ACE Invstgtn

Att3c Burden Memo ACE Invstgtn.docx

[ATSDR] Assessment of Chemical Exposures (ACE) Investigations

Att3c Burden Memo ACE Invstgtn

OMB: 0923-0051

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Attachment 3c –Assessment of Chemical Exposures (ACE) Investigations Burden Memo (0923-0051)

Shape1


1. ACE Investigation GenIC No.:



2. Title of Investigation:



3. Acute Incident


Investigated:







4. Date of Investigation:

Beginning:


End:


5. Name, CIO, and Contact Information of Lead Investigator:







Complete this section for each instrument used during the investigation.


Data Collection Method (check all that apply):

  • Questionnaire:

Face-to-face Interview

Telephone Interview

Self-administered Paper and Pencil

Self-administered Internet

  • Focus Group

  • Medical Chart Review

  • Hospital Survey

  • Laboratory Sample

  • Other (please specify):


Response Rate (if applicable):

Total No. Responded (A): ____________________

Total No. Sampled/Eligible to Respond (B): ____________________

Response Rate (A/B): ____________________


Burden Table (insert rows for additional respondent types if needed)

Data Collection Instrument Name

Type of Respondent (e.g., general public, health care providers, responders, employees of the company)

Number of Respondents

(A)

Number of Responses per Respondent

(B)

Burden per Response (minutes)

(C)

Total Burden

(in minutes;

A x B x C)





















File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
File TitleEmergency Epidemic Investigations
Authorlmp2
File Modified0000-00-00
File Created2024-10-07

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