Form 0920-1243 Att. C Investigation Protocol Template Generic Suicide_3

Attachment C

Form Approved

OMB No: 0920-1243
Exp. Date: xx/xx/xxxx

Public Reporting burden of this collection of information is estimated at X 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA  30333; Attn:  PRA (0920-1243).

Rapid Response Suicide Investigation Data Collection:

Generic Information Collection (GenIC) Investigation Protocol Template

TITLE

Provide a title for the investigation.

CDC STAFF LEADING INVESTIGATION

List the CDC staff leading the investigation.

INTRODUCTION

Describe the circumstances of the investigation, including the geographic location, any vulnerable population, and initiating event (e.g., partner requesting CDC assistance, CDC’s suicide monitoring that detected area or population with possible cluster or elevated suicide rates).

Specify which circumstances justify the Rapid Response Suicide Investigation Data Collection. Examples of circumstances, include, but are not limited to:

• Increased rate in suicidal behavior or suicide

• Specific description of vulnerable subpopulation(s)

• Possible or known suicide cluster or contagion

• Need for new information about trends, risk/protective factors, vulnerable populations (e.g., adolescents), and other topics (e.g., common methods/location) in suicidal behavior or suicides to inform prevention strategies

• Public or political concern (e.g., possible suicide cluster or increasing trends in a state, county, community or vulnerable population)

PURPOSE

Describe the objectives of the investigation. Specify the external partners (e.g., local, state, territory, and tribal health authorities; other federal agencies; local and state leaders; schools; or other partner organizations) involved with the urgent response. Describe the type of CDC technical assistance requested/provided. Describe the purpose of the data collection activities.

METHODS

Describe the proposed data collection methods.

Investigation and analytic objectives:

Investigation design:

Case definition(s):

Investigation population:

Sample design (if appropriate):

Data collection approach:

Power/sample size calculations/minimum detectable differences (if appropriate):

Respondents:

Anticipated burden hours:

BURDEN ESTIMATE

Data Collection Instrument Name	Type of Respondent	Data Collection Mode	No. Respondents (A)	No. Responses per Respondent (B)	Burden per Response in Minutes (C)	Total Burden in Hours (A x B x C)/60*

Data analysis plan:

Intended application of findings:

RESULTS AND DISSEMINATION

Describe how results will be synthesized and reported to the external partner.

INVESTIGATION CONSIDERATIONS

Explain why the Privacy Act does or does not apply. If applicable, describe steps being taken ensure privacy of respondent data?:

Describe whether or not the investigation requires Human Subjects Protections. Attach NCIPC Determination of Human Subjects review?:

Are incentives provided? If yes, provide a justification for incentive plan.:

INVESTIGATIVE TEAM

List full investigative team, including CDC staff and external partner staff.

CITATIONS

Provide references for works cited. 

ATTACHMENTS

Provide the draft data collection forms to be used in the investigation; specify respondents for each form.

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