Form Approved OMB
Approval No. 0920-xxxx Expiration
Date: xx/xx/xxxx
The process to request assistance for medical countermeasures (MCM) assets involving
a. Federal disaster declaration
b. Isolated, individual, or time-critical to the jurisdiction
c. Coordination with tribal governments (if applicable)
POD security plans in place
Process for dispensing MCM in POD and dispensing vaccination clinics (DVC) sites include
a. Flow diagram
b. Algorithm for dispensing medical countermeasures
c. Record/log of drugs dispensed
d. Investigational New Drug (IND)
e. Emergency Use Authorization (EUA)
MCM procedures for cold chain management
General point-of-dispensing (POD) information
• POD name
• POD operation type (open/closed)
• POD planning type (primary, back-up, tertiary)
• Address
• POD used as antibiotic dispensing clinic (y/n)
• POD used as dispensing vaccination clinic (y/n)
• Written agreement in place (y/n)
POD Detail
• Type of facility (academic institution, athletic complex, community center, government facility, etc.)
• Primarily walk through, drive through, combination (select 1)
• Staffing is based on a tiered approach (y/n)
• Total staff needed for antibiotic dispensing operation
• Total staff currently identified for antibiotic dispensing operation
• Total staff needed for vaccine administration clinic/DVC (if applicable)
• Total staff currently identified for antibiotic dispensing operation
Public reporting burden of
this collection of information is estimated to average 420
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).
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Garcia, Albert (CDC/DDPHSIS/CPR/OD) |
File Modified | 0000-00-00 |
File Created | 2022-03-03 |