Burden memo template

Attachment E. Burden Memo

GenIC No.:
EPI AID No. (if applicable):
Requesting entity (e.g., jurisdiction):
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:

Complete the following for each instrument used during the investigation.

Data Collection Instrument 1

Name of Data Collection Instrument:

Type of Respondent

General public Healthcare staff Laboratory staff Patients Restaurant staff
Other (describe):

Data Collection Methods (check all that apply)

Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):

Data Collection Mode (check all that apply)

Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil Questionnaire (describe):
Self-administered Internet Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):

Response Rate (if applicable)

Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

Data Collection Instrument 2

Name of Data Collection Instrument:

Type of Respondent

General public Healthcare staff Laboratory staff Patients Restaurant staff
Other (describe):

Data Collection Methods (check all that apply)

Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):

Data Collection Mode (check all that apply)

Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil Questionnaire (describe):
Self-administered Internet Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
Other (describe):

Response Rate (if applicable)

Total No. Responded (A):
Total No. Sampled/Eligible to Respond (B):
Response Rate (A/B):

Data Collection Instrument 3

Name of Data Collection Instrument:

Type of Respondent

General public Healthcare staff Laboratory staff Patients Restaurant staff
Other (describe):

Data Collection Methods (check all that apply)

Epidemiologic Study (indicate which type(s) below)
Descriptive Study (describe):
Cross-sectional Study (describe):
Cohort Study (describe):
Case-Control Study (describe):
Other (describe):
Environmental Assessment (describe):
Laboratory Testing (describe):
Other (describe):

Data Collection Mode (check all that apply)

Survey Mode (indicate which mode(s) below):
Face-to-face Interview (describe):
Telephone Interview (describe):
Self-administered Paper-and-Pencil Questionnaire (describe):
Self-administered Internet Questionnaire (describe):
Other (describe):
Medical Record Abstraction (describe):
Biological Specimen Sample
Environmental Sample
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 Respondent	No. Respondents (A)	No. Responses per Respondent (B)	Burden per Response in Minutes (C)	Total Burden in Hours (A x B x C)/60*

Return completed form and a blank copy of each final data collection instrument within 5 business days of data collection completion to the EEI Information Collection Request Liaison, Danice Eaton (dhe0@cdc.gov).

EEI Information Collection Request Liaison:

Danice Eaton, PhD, MPH

EIS Program Staff Epidemiologist

Epidemiology Workforce Branch

Division of Scientific Education and Professional Development

Centers for Disease Control and Prevention

2400 Century Center, MS E-92

Office: 404.498.6389
Deaton@cdc.gov

Page 8 of 8 Form Updated: 9/4/2014