ATSDR Public Meeting Survey Sign-In Sheet
ATSDR Communication Activities Survey (ACAS)
AttE ACAS Sign-in Sheet 20201130
OMB: 0923-0055
ATTACHMENT E. ACAS Sign In Sheet
ATSDR
estimates the average public reporting burden for this collection
of information as 2 minutes per survey, including the time for
reviewing instructions, searching existing data/information
sources, gathering and maintaining the data/information 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 (0923-0055).
Form
Approved OMB
No. 0923-0055 Exp.
Date 06/30/2020
Form
Approved OMB
No. 0923-0055 Exp.
Date 06/30/2020
Address: _________________________________________________
Date of Community Meeting: _____________________________
CONSENT: Taking part in the ACAS is completely voluntary. The information on the sign in sheet will only be used to recruit and contact ACAS participants and for no other purpose. You may skip any question or stop at any time. Your responses and identity will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release information that may identify you in any ATSDR reports. Please be sure to get all of your questions about the survey answered by ATSDR before you begin. By proceeding, you indicate that you are 18 years of age or older, and CONSENT to participate in this survey.
Note: This information will not be shared with other agencies.
|
Email (for online survey only) |
How would you like to take the survey? |
1 |
|
|
2 |
|
|
3 |
|
|
4 |
|
|
5 |
|
|
6 |
|
|
7 |
|
|
8 |
|
|
9 |
|
|
10 |
|
|
11 |
|
|
12 |
|
|
13 |
|
|
14 |
|
|
15 |
|
|
16 |
|
|
17 |
|
|
18 |
|
|
19 |
|
|
20 |
|
|
21 |
|
|
22 |
|
|
23 |
|
|
24 |
|
|
25 |
|
|
26 |
|
|
27 |
|
|
28 |
|
|
29 |
|
|
30 |
|
|
31 |
|
|
32 |
|
|
33 |
|
|
34 |
|
|
35 |
|
|
36 |
|
|
37 |
|
|
38 |
|
|
39 |
|
|
40 |
|
|
41 |
|
|
42 |
|
|
43 |
|
|
44 |
|
|
45 |
|
|
46 |
|
|
47 |
|
|
48 |
|
|
49 |
|
|
50 |
|
|
51 |
|
|
52 |
|
|
53 |
|
|
54 |
|
|
55 |
|
|
56 |
|
|
57 |
|
|
58 |
|
|
59 |
|
|
60 |
|
|
61 |
|
|
62 |
|
|
63 |
|
|
64 |
|
|
65 |
|
|
66 |
|
|
67 |
|
|
68 |
|
|
69 |
|
|
70 |
|
|
71 |
|
|
72 |
|
|
73 |
|
|
74 |
|
|
75 |
|
|
76 |
|
|
77 |
|
|
78 |
|
|
79 |
|
|
80 |
|
|
81 |
|
|
82 |
|
|
83 |
|
|
84 |
|
|
85 |
|
|
86 |
|
|
87 |
|
|
88 |
|
|
89 |
|
|
90 |
|
|
91 |
|
|
92 |
|
|
93 |
|
|
94 |
|
|
95 |
|
|
96 |
|
|
97 |
|
|
98 |
|
|
99 |
|
|
100 |
|
|
101 |
|
|
102 |
|
|
103 |
|
|
104 |
|
|
105 |
|
|
106 |
|
|
107 |
|
|
108 |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Olivia Harris: NCEH/ATSDR Office of Science |
| File Modified | 0000-00-00 |
| File Created | 2021-09-11 |
© 2024 OMB.report | Privacy Policy