Form Approved
OMB Control No. 0920-XXXX
Exp. Date: XX/XX/XXXX
FOR OFFICE USE ONLY: Insert Onset Date - End Date: [Place Lab ID label here]
|
||
Urine |
Date: |
Time: |
Semen |
Date: |
Time: |
0 1 2 3 4 5 6 7 8 9 10+ times |
||
0 1 2 3 4 5 6 7 8 9 10+ days |
||
Yes No |
||
Yes No |
||
Yes No |
||
Yes No |
Thank you for including this survey in your return kit! Please email ZikaMalesStudy@cdc.gov with any questions.
Public reporting burden of this collection of information is estimated to average 1 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, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX
File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
Author | Hook, Sarah A. (CDC/OID/NCEZID) |
File Modified | 0000-00-00 |
File Created | 2021-01-23 |