Response Specific Data Element Form

Attachment 6. Final Response-Specific Data Elements Form

FINAL RESPONSE-SPECIFIC DATA ELEMENTS FOR THE GENERIC CLEARANCE FOR THE COLLECTION OF MINIMAL DATA NECESSARY FOR CASE DATA DURING AN EMERGENCY RESPONSE (0920-XXXX)

Response-specific data elements to be collected during the emergency response.

Instruction: On an attached spreadsheet, or in the table below, include each response-specific data element that was collected during the response, including those initially included on the Minimal Data Necessary for Case Data During an Emergency Response Form. Include each data element’s definition, and its value set. Include the precedent for using the definition and value set, including whether the definition and value set are currently used for routine surveillance (e.g., definition and value set used for routine influenza surveillance) and the situation or event where the definition and value set were used in the past (e.g., definition used during the COVID-19 response; value set used in the United States Core Data for Interoperability (USCDI)). Include dates of use. Include an overall justification for using the data element and include what information and insight it will provide that is not already provided. Note that the definition and value set precedent and overall justification can apply to more than one data element.

Name	Definition	Value Set	Definition and Value Set Precedent	Overall Justification

CERTIFICATION: Please read the certification carefully. Type your name to validate that you are providing certification. Note: If you incorrectly certify, the collection will be returned as improperly submitted or it will be disapproved. Certification should be signed by the current Emergency Response Lead.

I, [INSERT NAME OF EMERGENCY RESPONSE LEAD], certify the following to be true:

1. This final and complete Response-Specific Data Elements Form includes a complete list of response-specific data elements that were collected during the response including response-specific data elements that were not listed on the initial request form.

Emergency Response Lead Name:

Date of Certification:

REQUESTED APPROVAL DATE (MM/DD/YYYY): Instruction: Indicate the date by which approval is needed.

DATE SUBMITTED TO INFORMATION COLLECTION REQUEST LIAISON (MM/DD/YYYY): Instruction: Please indicate the date the request is submitted to the ICRL.

E-mail the completed form to the Information Collection Request Liaison (ICRL), FIRST LAST, at XXXX@cdc.gov. If submitting outside business hours and immediate approval is needed, call XXX-XXX-XXXX to notify the ICRL of the submission.

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