Interest Form

Research to Reduce Time to Treatment for Heart Attack/Myocardial Infarction for Rural American Indians/Alaska Natives (AI/AN)

Attachment 10

Interest Form

Form Approved

OMB No. 0920-xxxx

Exp Date xx /xx/xxxx

Research to Reduce Time to Treatment for Heart Attack/Myocardial Infarction for Rural American Indians/Alaska Natives (AI/AN)

Interest Form

We need your help. As a community member, medical provider or survivor of a heart attack, we believe that you can help to identify some of the issues that prevent people from getting the treatment they need in a timely way. Your thoughts and opinions are vital to gaining better understanding of this very important subject.

If you are able to participate in this project, please fax this form to our office at the number listed below. We ask that you fill out the contact information so that we can send you a copy of the consent form and the questionnaire so that you can review them. We will call you at the number you list at the time that you indicate is best for your schedule.

Name (Please Print): ____________________________________________________________

Mailing address:_______________________________________________________________

City/State/Zip:__________________________________________________________________

Phone: _______________________________________________________________________

Cell Phone: ____________________________________________________________________

Work Phone: __________________________________________________________________

Best time to contact: _____________________________________________________________

Signature: _____________________________________________________________________

Tribal Affiliation:_______________________________________________________________

FAX TO: 605-964-3415 or SEND TO: Missouri Breaks HCR 64, Box 52 Timber Lake, SD 

57656

For questions call us at: 1-866-865-3418 Monday through Friday 8 am to 5 pm Mountain time

Ask for Marcia, Melissa or Sue

Public reporting burden for this collection of information is estimated to average 3 minutes per response, including 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, NE, MS D-74, Atlanta, GA 30333, ATTN:PRA (0920-xxxx).