Att 5_DSHPSWA Previous Survey

Early Hearing Detection and Intervention
Hearing Screening and Follow-up Survey
Reinstatement with Change
Marcus Gaffney
Project Officer
1600 Clifton Rd. MS E-88
Atlanta, GA 30333
(404) 498-3031
MGaffney@cdc.gov

Attachment 4C
4D:
CDC EHDI Hearing Screening and Follow-up Survey (HSFS) Screen Shots

Form Approved
OMB No. 0920-0733
Exp. Date XX/XX/XXXX

Parts 1:
Screening Diagnosis and Intervention

Burden Notice: The public reporting burden of this collection of information is estimated to average 4 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/ATSDR
Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333 ATTN: PRA (0920-0733)

Part 2 :
Type and Severity
DSHPSHWA System
&
ASHSA System

Part 3:
Demographics