Healthcare System Surge Capacity at the Community Level
Request for OMB Approval
March 4, 2011
Contact:
Amy McMillen
National Center for Emerging and Zoonotic Infectious Diseases
Centers for Disease Control and Prevention
1600 Clifton Road, N.E.
Atlanta, Georgia 30333
Phone: (404) 639-1045
Fax: (404) 639-3039
Email: amcmillen@cdc.gov
Healthcare System Surge Capacity at the Community Level
This is a request for OMB approval of a new data collection. CDC is requesting a one year approval to collect data for this project.
A. Justification
1. Circumstances Making the Collection of Information Necessary
The Healthcare Preparedness Activity (Activity), Division of Healthcare Quality Promotion (DHQP) at the Centers for Disease Control and Prevention (CDC) works with other federal agencies, state governments, medical societies and other public and private organizations to promote collaboration amongst healthcare partners, and to integrate healthcare preparedness into federal, state and local public health preparedness planning. The goal of the Activity is to help local communities’ healthcare delivery and public health sectors effectively and efficiently prepare for and respond to urgent and emergent threats.
The Activity has engaged with multiple communities to explore how they can develop plans that address healthcare system surge during an influenza pandemic. Workshops conducted in 2008 with several pilot communities have included a wide spectrum of healthcare partners (acute and outpatient settings) as well as local public health and emergency management agencies; participants have expressed that the inclusion of a broad base of partners improved their pandemic planning and response to the 2009 H1N1 influenza pandemic. Results from national assessment programs of state/local plans also suggest that strong, existing collaborations with private and public response partners are associated with more robust response plans. This leads to a hypothesis that the more ‘prepared’ communities are those that appoint multidisciplinary community partners and leaders to plan together for emergency situations or, alternatively, are those already exploring coordinated mechanisms to address everyday emergency department ‘surge’ within their community.
The information provided by pilot communities is useful but is not derived from any formal study or evaluation, and cannot be generalized to inform policy or guidance regarding surge management in a pandemic. To address that need, the Activity will examine community responses to H1N1 as a model exploring the ability of healthcare providers and public health to meet a surge in demand.
Surge is defined as a marked increase in demand for resources such as personnel, space and material (Kelen, 2006) .iHealth care providers manage both routine surge (predictable fluctuations in demand associated with the weekly calendar, for example) as well as unusual surge (larger fluctuations in demand caused by rarer events such as pandemic influenza). Except in extraordinary cases, providers are expected to manage surge while adhering to their existing standards for quality and patient safety. In many communities, providers develop internal strategies for managing surge and also work with public health agencies and with other providers to form collaborations (Felland, 2008).iiThese collaborations bring together a diverse group of stakeholders, including private and public hospitals and state and federal agencies (including CDC).
Currently, health care organizations are expected to prepare for and respond to surges in demand ranging from a severe catastrophe (for example, a nuclear detonation) to more common, less severe events (for example, a worse-than-usual influenza season). The Centers for Disease Control and Prevention and other federal agencies have dedicated considerable funding and technical assistance towards developing and coordinating community-level responses to surges in demand, but it remains a difficult task. Among the challenges:
Surge response is coordinated by overlapping state and federal public agencies, but many resources necessary for a response are concentrated in the private sector.
Disaster planning is generally organized along state and regional lines, but this may not reflect the structure or distribution of private sector resources within a market. For example, a community considered a single unit for the purpose of surge response may include two hospitals owned by different, competing national chains that would not collaborate under ordinary circumstances.
If a surge does not reach the level of a major disaster where regular business is disrupted, health care providers who follow recommended response guidelines may be acting against their own business imperatives. The extent to which this represents a conflict may vary widely by the type of provider and the nature of the local market.
Key areas of the private sector, such as independent primary care practices and skilled nursing facilities, are often left out of surge planning altogether (Hogg 2006; Cowan 2005). iii,iv
U.S. government grant guidance has referred to the establishment of collaborations as a strategy to improved healthcare response to disasters. A collaboration refers to a community-based effort, beginning before a disaster/surge episode and involving multiple stakeholders, through which local health care providers both receive guidance from regional/national public health authorities (including CDC) and contribute guidance about the characteristics of their own community.
While there is extensive research on managing collaborations during times of extraordinary pressure where response to surge takes precedence over other activities, less is known about developing and maintaining integrated collaborations during periods where the system must respond to unusual surge but also continue the routine provision of health care. In particular, studies have not explored how these collaborations can build on sustainable relationships between a broad range of stakeholders (including primary care providers) in communities with different market structures and different degrees of investment in public health (Health Research Institute, 2007). v
CDC will be working with the Center for Studying Health System Change (HSC), a nonpartisan research institution that studies local health care markets across the US to examine the broad role collaborations have played and examine what additional guidance or assistance these community healthcare providers may need to accomplish the management of surge in an event. HSC has previously conducted research in disaster preparedness and surge capacity and has extensive experience performing qualitative research involving health care providers and state and local public health leadership. It is expected that this research study will help refine current preparedness activities by identifying real-world barriers to coordination seen during the preparation for pandemic H1N1 influenza in a variety of health care markets.
This study aims to generate information about the role of community-based collaborations in disaster preparedness that the CDC can use to develop its programs guiding and supporting these collaborations. Specifically
How do collaborations affect preparedness and surge capacity? What types and characteristics of collaborations are most/least useful?
What are the barriers and facilitators to collaboration both between different types of organizations (e.g., hospitals and primary care practices) and within a single type of organization (e.g., between competing hospitals) for the purpose of surge management?
How is guidance from CDC received by collaborations and individual stakeholders?
Little is known about the perceptions of key stakeholders (primary care providers) regarding their role in preparedness and surge capacity; a qualitative approach will allow investigators to explore unexpected findings. Prior qualitative research done at HSC has demonstrated a gap in knowledge on the role and perceptions of stakeholders in emergent public health needs, particularly among practitioners and local health departments. By using grounded theory and qualitative methods for this exploratory study of the role of collaborations in disaster preparedness, investigators can capture and compare a variety of different participants’ perceptions, which may be nuanced and complex.
This project will explore barriers and facilitators to coordination on surge response in ten communities, eight of which have been studied longitudinally since the mid-1990s as part of HSC’s Community Tracking Study (CTS). CTS Site Visit methodology is described at http://www.hschange.org/index.cgi?data=17 (accessed 9/30/10).vi In short, interviews of local healthcare stakeholders will be conducted at 10 sites.
The primary audiences for this project are (1) community-based stakeholders (emergency providers, primary care providers and local public health leaders) and (2) the CDC. The investigator team is led by an HSC researcher who is also a practicing emergency physician (ED), and CDC is participating in the study design. While other stakeholders are not participating directly in the study design, the open-ended and adaptive nature of qualitative research will allow participants to express their views and clarify their needs throughout the process.
Authorizing Legislation comes from Section 301 of the Public Health Service Act (42 U.S.C. 241) (Attachment A).
Privacy Impact Assessment
Overview of the Data Collection System
This study will use qualitative methods, including telephone interviews guided by semi-structured protocols (see Attachments C and D) designed to elicit key themes from respondents. Interviewers will be able to probe further or deviate from protocols to the extent that respondents reveal new information. The following specific research questions will be addressed to provide an in-depth look at the role of collaborations in building community surge capacity:
How do collaborations affect preparedness and surge capacity? What types and characteristics of collaborations are most/least useful?
What are the barriers and facilitators to collaboration both between different types of organizations (e.g., hospitals and primary care practices) and within a single type of organization (e.g., between competing hospitals) for the purpose of surge management?
3. How is guidance from CDC received by collaborations and individual stakeholders?
Items of Information to be Collected
Name
Title
Email address
Telephone number
Responses to interview questions
Identification of Website(s) and Website Content Directed at Children Under 13 Years of Age
None
2. Purpose and Use of Information Collection
Information collected by the study will inform strategies to promote DHQP’s support of sustainable community-level collaboratives that can generate effective responses to pandemic illness and other surges in healthcare demand. Specifically, DHQP will use provider and preparedness respondents’ reports of their experiences working in collaborations to make future coalition-building efforts more sustainable for participants and responsive to community providers’ needs and concerns.
Findings will also be widely disseminated to federal, state and local policymakers, as well as private sector health care decision makers, via CDC’s website as well as HSC’s website, media outreach, email alerts, conference presentations and policymaker briefings.
Privacy Impact Assessment Information
This study will collect information from respondents about their participation in collaborations related to healthcare preparedness and surge in their communities. It will not collect any information that could be used to identify individual patients. HSC (the contractor) will collect the respondent’s name, telephone number, email address, organizational affiliation and title. This information will be used for case tracking purposes or for clarification call backs. CDC has requested that the contractor not share respondents’ identifying information with CDC staff so that respondents can be encouraged to speak freely about CDC and its role in preparedness activities. Advisement information is contained in a letter to respondents located in Attachment E.
All electronic files will be password-protected and accessible only from a secured network. When not in use by project staff, all printed information or materials that could potentially identify participants in the study will be stored in locked cabinets that are accessible only to team members. Data (interview transcripts) will be kept for one year after the completion of the study, to allow time to address any queries or concerns. Identifying information (contact information) will be filed and retrieved by the name of the individual.
The proposed data collection will likely have little or no effect on respondents’ privacy.
3. Use of Improved Information Technology and Burden Reduction
HSC and CDC will collect data through an established qualitative research methodology, which includes telephone interviews with study respondents. Because most interview questions are open-ended to allow for in-depth exploration of issues, electronic submission of responses is not a viable option.
4. Efforts to Identify Duplication and Use of Similar Information
CDC has conducted a literature review and conferred with internal staff and outside preparedness experts about ongoing research projects. From this review, CDC has not identified any in-depth interview data from practitioners and state and local preparedness experts on the collaborative efforts that are the focus of this study. Several studies have identified the difficulty of involving primary care providers in sustainable preparedness efforts, but the causes of this difficulty and the ways stakeholders have sought to build collaborations have not been explored in detail, highlighting the need for and design of this study.
5. Impact on Small Businesses or Other Small Entities
This research will involve telephone interviews with respondents at physician practices and local community preparedness associations, many of which may be small businesses. Study participation is voluntary and HSC and CDC will be respectful of study participants’ time. Interviews will be scheduled at times convenient for respondents. The interview protocols consist of the minimum questions required for study purposes. Individual interviews will last no more than an hour.
6. Consequences of Collecting the Information Less Frequently
This is a one-time collection.
7. Special Circumstances Relating to the Guidelines of 5 CFR 1320.5
This request is consistent with the general information collection guidelines of 5 CFR 1320.5(d)(2). No special circumstances apply.
8. Comments in Response to the Federal Register Notice and Efforts to Consult Outside the Agency
A 60 day notice was published in the Federal Register on Monday, January 3, 2011, Volume 76, No. 2, pp. 147-148. No public comments were received.
B. Officials and researchers who have special interest and expertise in the individual activities and topics will be contacted as necessary. The following individuals were consulted for the development of this request:
Laurie Felland, MA Assistant Director of Site Visits and Senior Health Researcher 600 Maryland Avenue SW Suite 550 Washington, DC 20024 |
Joy Grossman, PhD Senior Health Researcher 600 Maryland Avenue SW Suite 550 Washington, DC 20024 |
Ms. Felland’s and Dr. Grossman’s biosketches are available at http://www.hschange.org/index.cgi?file=staff.
9. Explanations of Any Payment or Gift to Respondents
There will be no remuneration to respondents.
10. Assurance of Privacy of Data Provided to Respondents
Individuals and organizations will be assured of the privacy of their replies under Section 934(c) of the Public Health Service Act, 42 USC 299c-3(c). They will be told the purposes for which the information is collected and that, in accordance with this statute, any identifiable information about them will not be used or disclosed for any other purpose without their prior consent, unless required by law upon the demand of a court or other governmental authority.
This study will collect information from respondents about their participation in collaborations related to healthcare preparedness and surge in their communities. It will not collect any information that could be used to identify individual patients. HSC (the contractor) will collect the respondent’s name, telephone number, email address, organizational affiliation and title. This information will be used for case tracking purposes or for clarification call backs. CDC has requested that the contractor not share respondents’ identifying information with CDC staff so that respondents can be encouraged to speak freely about CDC and its role in preparedness activities. No identifying information will be transmitted to CDC. Advisement information is contained in a letter to respondents located in Attachment E.
This study has been declared exempt by the CDC IRB.
Privacy Impact Assessment Information
A. This submission has been reviewed by ICRO, who determined that the Privacy Act does not apply..
B. All electronic files will be password-protected and accessible only from a secured network. When not in use by project staff, all printed information or materials that could potentially identify participants in the study will be stored in locked cabinets that are accessible only to team members. Data (interview transcripts) will be kept for one year after the completion of the study, to allow time to address any queries or concerns. Identifying information (contact information) will be filed and retrieved by the name of the individual.
C. Verbal consent will be obtained at the beginning of each interview. See the script interviewers use to explain the study located at Appendix C and D.
D. Respondents are informed about the voluntary nature of their response.
11. Justification for Sensitive Questions
No questions of a sensitive nature will be asked. Further, during the introduction to the interview, respondents will be informed that their participation is voluntary and that they can refuse to answer any question.
12. Estimates of Annualized Burden Hours and Costs
A. Interviews will be conducted at a total of 63 organizations over the one year data collection phase of this project. Within each of the ten communities studied, two emergency practitioner respondents (one from a safety-net hospital and one from a non-safety-net hospital), two primary care providers (one from a large practice and one from a small practice) and two local preparedness experts (one from the County or local public health agency, and one coordinator or collaboration leader) will be interviewed. In three sites (Phoenix, Greenville and Seattle) an additional respondent will be identified from an outlying rural area to offer the perspective of providers in those communities.
B. Cost estimates associated with organizations’ time to participate in this research were derived from the Department of Labor Occupational Employment Statistics for regions corresponding to each community in the study. The following categories were used:
Emergency practitioners were classified as Physicians and Surgeons, all other (291069).
Primary care providers were classified as Family and General Practitioners (291062) and Internists, General (291063). We assumed for purposes of cost calculation that primary care respondents in the urban sites would be evenly divided between internists and family practice/general practice practitioners, and rural respondents would be family practice/general practice practitioners.
Preparedness respondents were classified as Medical Scientists, other than Epidemiologists (191042), a category that includes public health scientists. Because hourly wages for Greenville-Maudlin-Easley, SC were not available for this category, hourly wages for Charlotte-Gastonia-Concord were used.
Exhibit 1 shows the estimated annual burden hours for each organization’s time to participate in this research. The total annual burden is estimated to be 63 hours.
Exhibit 1: Estimated Annual Burden Hours
Respondent Category
|
Number of Respondents |
Number of Responses per Respondent |
Average Burden Response (in hours) |
Total Burden (in hours) |
Emergency Department and Primary Care |
43 |
1 |
1 |
43 |
Public Health and Preparedness/Coalition Leader |
20 |
1 |
1 |
20 |
TOTAL |
63 |
|
|
63 |
Exhibit 2 shows the estimated annual cost burden associated with organizations’ time to participate in this research. The average hourly wage was calculated by averaging the mean wages of professionals within the given categories across the ten study sites. Burden in hours is taken from Exhibit 1. The total annual cost burden is calculated by multiplying the mean hourly wage of each category by the burden in hours from that category, and summing these totals from both categories. The total cost burden is estimated to be $4255.32.
Exhibit 2. Estimated Annual Cost Burden to Respondents
Respondent Category |
Average Hourly Wage |
Burden (in hours) |
Cost Burden |
Emergency Department and Primary Care |
$81.27 |
43 |
$3494.52 |
Public Health and Preparedness/Coalition Leader |
$38.04 |
20 |
$760.80 |
TOTAL |
|
63 |
$4255.32 |
13. Estimates of Other Total Annual Cost Burden to Respondents or Record Keepers
There are no direct costs to respondents other than their time to participate in this study.
14. Annualized Cost to the Government
The estimated total cost to the Federal Government for this project is $183,119.00 over the one year period of data collection. Exhibit 3 provides a breakdown of the estimated total costs..
Exhibit 3. Estimated Costs to Federal Government
Cost Component* |
Total Cost (in dollars) |
Project Development and Project Management (including CDC staff time) |
47,370 |
Data Collection Activities |
86,670 |
Data Analysis |
17,555 |
Publication and Dissemination of Results |
31,524 |
Total |
183,119 |
*Costs represent fully loaded rates
15. Explanation for Program Changes or Adjustments
This is a new collection of information.
16. Plans for Tabulation and Publication and Project Time Schedule
Task |
Estimated timeline following OMB clearance |
Respondent selection and start of scheduling |
Months 1-3 |
Conduct interviews |
Months 4-8 |
Complete notes |
Month 8 |
Data analysis and outline |
Month 9 |
First draft |
Month 10 |
Final product |
Month 11 |
17. Reason(s) Display of OMB Expiration Date is Inappropriate
None
18. Exceptions for Certification for Paperwork Reduction Act Submissions
None
B. Collections of Information Employing Statistical Methods
This proposed research will use a purposive sample, therefore study findings cannot be statistically generalized to the respondent universe. However, the lessons learned from this qualitative research will inform strategies to promote the establishment of community collaborations being developed by CDC and other Department of Health and Human Services agencies, as well as state and local governments and private health care organizations.
The key units of observation for the proposed qualitative study are emergency practitioner leaders, community-based practitioner leaders, and preparedness experts in ten communities representing all geographic regions of the US and including large cities, midsize cities and rural areas. HSC and CDC expect to invite approximately 100 respondents in order to identify 63 respondents willing to participate. These 63 respondents will include ten emergency practitioner leaders working at safety-net hospitals, ten emergency practitioner leaders working at hospitals that do not have safety-net missions, ten primary care leaders representing large practices and ten primary care leaders representing small practices (the 2008 HSC Health Tracking Physician Survey found the median primary care physician worked in a practice of four physicians, so small primary care practices will be defined as practices with fewer than four physicians), ten preparedness experts representing local or county government and ten preparedness efforts representing community-based associations or coalitions.
Study sites
Initial CTS study sites were selected randomly to be nationally representative of communities with populations over 200,000. CTS sites used for this study include: Boston, MA; Greenville, SC; Indianapolis, IN; Miami, FL; Orange County, CA; Phoenix, AZ; Seattle, WA; and Syracuse, NY. The two additional sites are New York City, NY and Chicago, IL. The rationale for site selection was as follows:
Core sites
Six CTS sites (Boston, Greenville, Phoenix, Seattle, Orange County, Miami) were previously studied in the HSC Issue Brief Developing Health System Surge Capacity: Community Efforts in Jeopardy because of their efforts on surge capacity. This study gathered extensive information about community efforts in preparing for disasters, although collaboration was not a specific focus. Our findings will build on the work done in the earlier Issue Brief, allowing us to focus more efficiently on the specific impact of collaboration among private-sector entities and between private and public sectors.
Additional sites
In order to include other regions of the country several additional sites were added. New York City (not a CTS site), which was also included in Developing Health System Surge Capacity: Community Efforts in Jeopardy because of its significant investment in preparedness.
Indianapolis (CTS site) and Chicago (not a CTS site) were added to the sites in order to include more Midwestern region representation. Interviews in these communities will probe on the effects of CDC activities, if any. The Syracuse (CTS site) was added to include more rural respondents in the study.
Eligible practitioners in the CTS communities will be identified from three sources: (1) practitioners identified as leaders by current CTS site visit contacts; (2) media reports and publicly available documents describing each community’s response to H1N1; and, (3) other practices and preparedness experts participating in the study. Practices will be selected for the study purposively from among eligible practices to vary in size and specialty.
Exhibit 5 identifies the individual respondent types within each type of organization and outlines the total numbers of individual respondent interviews and respondent organizations in each category.
Exhibit 5. Target Respondent Organizations and Individual Respondent Types
Sampling: The sample population is targeted to include at least 63 respondents identified through medical societies and local or state health departments. This purposive sampling approach has been useful in the past in identifying informative interview subjects and/or those most familiar with the topic of study.
Estimated number of participants:
Organization Type |
Respondent Type |
Interview Length |
Number of participants |
Emergency Department |
Private, non-safety net |
45-60 |
10 |
Public/safety net |
45-60 |
10 |
|
Primary Care (including Community Health Centers) |
Larger practice |
45-60 |
10 |
Solo/2 physician practice |
45-60 |
10 |
|
Preparedness |
Public/Department of Health |
45-60 |
10 |
Health care preparedness coordinator/collaboration leader |
45-60 |
10 |
|
Rural (GV, PX, SE only) |
Clinician-leader at rural site (ED or PC) |
45-60 |
3 |
PROJECT TOTAL |
7 |
780 min |
63 |
Participant Recruitment. Participants will be recruited either by phone, e-mail, or fax depending on availability of the participant’s contact information. Attachment E is a sample invitation letter. The purpose of the communication is to explain the study, gain respondents’ agreement to participate and schedule the interviews. Each respondent who agrees to participate in the study will receive a written confirmation of the interview date and time by e-mail or fax (see Attachment G).
Interviews. In-depth interviews will be conducted by two-person teams, which will be comprised of a lead interviewer and a note taker. Respondents will be reminded of the focus of the study and the way their information will be used. The interviews will follow semi-structured protocols. Two protocols tailored to different respondent types have been developed (see Attachments C and D). The following domains of information will be explored:
Background
Market information
Non-surge collaboration
Non-surge competition
Framework/infrastructure for disaster response
Information on surge planning and H1N1
Details of disaster/surge plan
How did H1N1 affect organization
Details of H1N1 preparation
Perceptions of response and role of collaborations
Facilitators in response
Barriers in response
Interview notes will be typed and assigned initial codes by the note taker and reviewed for accuracy by the lead interviewer. Interview notes will be then be stored and coded using Atlas.ti (version 5.0) qualitative data analysis software.
Thank-you letters are routinely sent by mail (see Attachment H).
Respondent organizations are not being selected via probability-based sampling methods. A “response rate” has no clear meaning in the context of a qualitative study.
Based on previous experience, recruiting is likely to be more difficult for primary care practitioners. The strategy for identifying eligible practitioners includes contacting the state medical societies and previous primary care contacts to identify respondents who are interested in participating in the study. Every effort will be made to schedule interviews with these respondents at times most convenient for them.
The interview protocols were reviewed by Laurie Felland, MS, Assistant Director of Qualitative Research and Senior Health Researcher at HSC. Ms. Felland has extensive experience developing interview protocols for emergency practitioners, primary care practitioners and public health experts, and has conducted previous research on preparedness in CTS sites.
Because this study is qualitative, no statistical consultants were contacted.
AHRQ’s contractor, HSC, will be responsible for overseeing the recruitment of participants, conducting all of the interviews, and analyzing and reporting the findings. The principal investigator and project director is Emily Carrier, MD, MSCI. She can be reached by phone at 202-250-3533 or by email at ecarrier@hschange.org.
On a rolling basis over the course of the project, the project team will review interview notes and meet regularly to discuss the study’s key findings. Using an iterative process, the team will identify new themes as they emerge, explore and shape already identified themes in greater depth, and ensure that saturation in the data collection is reached. The interview data will be coded using the “integrated” approach described by Bradley et al. (2007). This approach combines the inductive development of codes from the data—the “grounded theory” approach (Glaser and Strauss 1967)—with a preliminary deductive “start list” of codes, which provides an initial organizing framework based on the existing literature (Miles and Huberman 1994). Atlas.ti software (Version 5.0) will be used to store, code and search the interview data for analysis. Data reduction will be achieved by summarizing coded interview data from Atlas.ti in data tables, which will then be analyzed to refine themes, weight the evidence supporting each finding, and identify respondent disagreements and disconfirming evidence.
List of Attachments
A. Section 301 of the PHS Act (42 U.S.C. 241).
B. 60 day Federal Register Notice
C. Interview Protocol 1
D. Interview Protocol 2
E. Invitation Letter
F. Follow-up Letter
G. Confirmation Letter
H. Thank-you Letter
I. Privacy of Data Pledge
J. Privacy of Data Agreement
K. 30 Day Federal Register Notice
iREFERENCES
Kelen G and McCarthy M, The Science of Surge. Academic Emergency Medicine 2006; 13: 1089-1093
iiFelland L, Katz A, Leibhaber A et al. Developing Health System Surge Capacity: Community Efforts in Jeopardy. Center for Studying Health System Change Issue Brief No. 5, June 2008
iiiHogg W, Huston P, Martin C et al. Enhancing Public Health Response to Respiratory Epidemics: Are Family Physicians Ready and Willing to Help? Canadian Family Physician 2006; 52: 1254-1260
ivCowan A, Ching P, Clark S. Willingness of Private Physicians to be Involved in Smallpox Preparedness and Response Activities. Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science. 2005; 3: 16-22
vClosing the Seams: Developing an Integrated Approach to Health System Disaster Preparedness. PricewaterhouseCoopers’ Health Research Institute 2007 CTS Site Visit methodology is described at http://www.hschange.org/index.cgi?data=17 (accessed 9/30/10)
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| File Title | Foreign Quarantine Regulations (42 CFR 71) |
| Author | aeo1 |
| File Modified | 0000-00-00 |
| File Created | 2021-02-01 |