Form 0920-24EH OHZDP Interest Intake Form

Form Approved

OMB Control No.: 0920-1154

Expiration date: 03/31/2026

 

OHZDP Interest Intake Form

• Name

• Title

• Organization

• Location

• E-mail Address

• Phone Number

• What is your intended use of the OHZDP Process?

  • To prioritize zoonotic diseases for all One Health sectors (human, animal, and environmental health)

  • To prioritize zoonotic diseases for one sector

  • To prioritize One Health issues (including but not limited to zoonotic diseases)

  • To prioritize infectious diseases

  • Other type of prioritization: please describe

• Would the OHZDP Process be used at a subnational, national, or regional (>1 country) level?

  • Subnational

  • National

  • Regional (>1 country)

  • Other: please describe

• Which organizations/agencies would be involved in the prioritization [check all that apply]?

  • Government Agencies [check all that apply]

    • Ministry of Health/Public Health

    • Ministry of Agriculture/Animal Health

    • Ministry of Environment/Wildlife

    • Other: please describe

  • Non-governmental organization

  • Academia

  • Other: please describe

• When are you planning on hosting this workshop? (Note: preparation for OHZDP workshops takes at minimum 3-4 months)

  • Free text

• Have facilitators that have previously participated in a OHZDP facilitator training been identified to facilitate this workshop?

  • Yes

  • No

• Has personnel/staff time for coordinating, preparing, and planning for this workshop been allotted?

  • Yes

  • No

• Have financial resources been identified to conduct a prioritization workshop (venue, travel/per diem, materials, printing, etc)?

  • Yes

  • No

• Are there any other details or information you would like to share with CDC’s One Health Office for consideration for access to the OHZDP Portal?

Public reporting burden of this collection of information is estimated to average 15 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 NE, MS H21-8, Atlanta, Georgia 30333; ATTN: PRA 0920-1154