Form 0920-0572 Planes, Trains and Autop Appendix B3 Response Form

Appendix B3. Response Form

This form is to be completed by the interviewer in the event of hand-held device malfunction. The interviewer will record the participant’s response to each interview question as it is given.

Planes, Trains, and Auto-Mobility: An Innovative Approach to Increase Walking in the Atlanta Hartsfield-Jackson Airport

Response Form

Public reporting burden of this collection of information is estimated to average 10 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 (0920-0572).

Concept Interview Response Form

1. A B C D __________________________________

2. A B C D

3. A B C (end interview)

4. Y (skip to 7) N

5. Y N (skip to 10)

6. Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Other ________________________________________________________________

(skip to 9)

7. Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Y N NS

Other ________________________________________________________________

8. 1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

1 2 3 4

9. Y ___________________________________________________________

10. A B

11. A B C D

12. A B

13. A B C D E _____________________

14. ______________________