Worksheet for Identifying Site Visit Interviews (Private Sector)

Form Approved

OMB No.: 0920-xxxx

Exp. Date: mm/dd/yyyy

Worksheet for scheduling site visit interviews

Public reporting burden of this collection of information is estimated to average 2 hours 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: OMB 0920-XXXX

Thank you for allowing us to visit your organization. These scheduling worksheets are samples and represent preferred time frames. Please feel free to adapt them to best meet the schedules of individuals/ groups we hope to interview while on site. Please let us know if travel from one location to another is required and build sufficient time into the schedule so that we can travel to each location. Please designate the dates from XXXX through XXXX, 2014 that are your first, second, and third choices for the consecutive 3-day site visit.

Thank you!

Your organization’s name: ______________________ Your name and title: _______________________

Dates of first choice: ­­­­­­­­­­­­­­­__For example January 6^th-8^th, 2014_

Dates of second choice: ____________________________

Dates of third choice: ______________________________

Day 1		Location (i.e., building, room #)
Morning
Time Slot	Interviewee(s)/ Role/ Contact Information	Special Notes/ Relevant Discussion Guide
7:30 – 8: 00 am
8:00 – 10:00 am
10:00 – 10:15 am	Break
10:15 – 11:00 am
11:00 – 12:00 am
12:00 – 1:00 pm	Lunch
Afternoon
1:00 – 2:00 pm
2:00- 3:00 pm
3:00 – 3:15 pm	Break
3:15 – 4:30 pm
4:30 – 5:30 pm

Day 2		Location (i.e., building, room #)
Morning
Time Slot	Interviewee(s)/ Role/ Contact Information	Special Notes/ Relevant Discussion Guide
7:30 – 8: 00 am
8:00 – 10:00 am
10:00 – 10:15 am	Break
10:15 – 11:00 am
11:00 – 12:00 am
12:00 – 1:00 pm	Lunch
Afternoon
1:00 – 2:00 pm
2:00- 3:00 pm
3:00 – 3:15 pm	Break
3:15 – 4:30 pm
4:30 – 5:30 pm

Day 3		Location (i.e., building, room #)
Morning
Time Slot	Interviewee(s)/ Role/ Contact Information	Special Notes/ Relevant Discussion Guide
7:30 – 8: 00 am
8:00 – 10:00 am
10:00 – 10:15 am	Break
10:15 – 11:00 am
11:00 – 12:00 am
12:00 – 1:00 pm	Lunch
Afternoon
1:00 – 2:00 pm
2:00- 3:00 pm
3:00 – 3:15 pm	Break
3:15 – 4:30 pm
4:30 – 5:30 pm

Please return this worksheet by fax to Revae Downey at 404-321-3688 or by e-mail at Revae.Downey@icfi.com.

You can reach Sarah O’Dell, ICF project manager, with any questions by phone at 404-321-3211 or by e-mail at Sarah.Odell@icfi.com

Thank you!