Study Salt Supplement Questionnaire

Form Approved

OMB No. 0920-xxxx

Expiration date: xx/xx/xxxx

Study Salt Supplement Questionnaire

Public reporting burden of this collection of information is estimated to average 5 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, NE, M/S D74, Atlanta, GA 30333, ATTN: PRA 0920-xxxx.

Over the time period you were asked to use the Study Salt Supplement at the table, how often did you use it when you were supposed to?

O Always

O Often/ Regularly

O Rarely/ A few times

O Never

Over the time period you were asked to use the Study Salt Supplement in home cooking, how often did you use it when you were supposed to?

O Always

O Often/ Regularly

O Rarely/ A few times

O Never

Describe any difficulties you had or record anything else you think we should know: