Form 0920-1352 Critical Contact Sheet

Form Approved

OMB Approval No. 0920-xxxx

Expiration Date: xx/xx/20xx

Critical Contact Sheet

• Primary CDC PHEP specialist -

• Backup CDC PHEP specialist or team lead -

• U.S. Marshal -

• Health department EOC -

• *Health department EOC: 24/7 phone number -

• Health department EOC: primary contact name -

• Health department EOC: primary phone number -

• Health department EOC: primary phone number -

• COOP EOC: primary contact name -

• EMA EOC: primary contact name -

• Health commissioner, secretary of health, state health officer (SHO), ministry of health -

• *PHEP Director -

• *MCM Coordinator -

• CHEMPACK coordinator -

• Law enforcement agencies responsible for MCM security: security contact name

• Backup law enforcement agency responsible for MCM security: security contact name

• Distribution (RSS) lead, supervisor, or chief: name

• Backup distribution lead: name

• State Department of Health Public information Officer (back-up)

• Influenza coordinator

• Immunization coordinator

• Laboratorian

• Epidemiologist

Public reporting burden of this collection of information is estimated to average 80 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx).