Sample Referral Form

Attachment E: Sample Referral Form

Community Assessment for Public Health Emergency Response

Form Approved
OMB No. 0920-XXXX
Exp. Date xx/xx/20xx

[Disaster name]
Confidential Referral Form
Date: __/__/____

Time: __:__

Cluster No.: _____
Interviewer’s Initials: _____
Name: _________________________________________________
Address: _______________________________________________
Contact Information:
Home telephone: ______ - _____ - _______
Cell phone: _____ - ____ - _______
E-mail: ______________________________

Summary of Need:
___________________________________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

Referral Made:

Yes

No

Referred to: __________________________________

Public reporting burden of this collection of information is estimated to average 2 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-XXXX).