Form Approved OMB
Approval No. 0920-1352 Expiration
Date: 10/31/2024
Process to request assistance for medical countermeasures (MCM) assets involving
Federal disaster declaration
No federal disaster declaration (possible state declaration)
Isolated, individual, or time-critical to the jurisdiction
Coordination with tribal government(s) (if applicable)
c.
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) protocols
e. Emergency Use Authorization (EUA) protocols
MCM procedures for cold chain management
General point-of-dispensing (POD) information
• POD name
• POD operation type
• POD planning type
• Address 1
Address 2
City
County
Zip code
Country
• POD used as antibiotic dispensing clinic
• POD used as dispensing vaccination clinic
• Written agreement in place
Type of facility
POD Detail
• Estimated population who will visit the POD
• 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 vaccine administration clinic DVC (if applicable)
• 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 (0920-1352).
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 |