Attachment 3

Attachment 3

Medical Record Abstraction Instruments

Medical Record Abstraction

Medical History Form for

Medical Monitoring Project (MMP)

VERSION 1

Medical record abstractor burden of this collection of information is estimated to average 60 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, Project Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0011). Do not send the completed form to this address.

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DEPARTMENT OF HEALTH AND HUMAN SERVICES

P

ublic Health Service

Centers for Disease Control and Prevention

Atlanta, GA 30333

• NOTE: The remaining medical records abstraction drawings are too large and were left out. Please check paper copy of attachment 3.