Appendix E. Annual Update Request (Telephone)

Appendix E

Annual Update Request (Telephone)

**Note: All proposed changes in the attached are highlighted in gray.

Form Approved

OMB No.0920- 0255

Exp. date: ­­__xx/xx/20xx

CDC National Prevention Information Network

Annual Update Request (Telephone)

Public reporting burden of this collection of information is estimated to average of 10 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, or respond to a collection of information unless it displays a currently valid 0MB 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 (0920-0255).

CDC National Prevention Information Network

Annual Update Request (Telephone)

1. Hello, is this ______________________ (name of organization)? (Make corrections as needed)

2. My name is _______________________ and I am calling from the CDC National Prevention Information Network. We are updating our database records and I am calling to see if the information we have about your organization is still current and complete. Your participation in this data collection is voluntary and you may end this call at any time.

3. The specific name of your organization is _________________________.

4. Do you have (use) an acronym for your company name?

5. Is your address still ____________________________? Do you have a different mailing address? If so, what is it?

6. Do you have an e-mail address? A website?

7. Is your main phone number still ______________? Is your fax number still ___________________? Do you have an 800 number or TTD? ___________ Are there any other phone numbers we should have? __________________

Modification: Change in question sequence.

8. The geographic area that your organization serves is _____________________.

9. What are the area codes for the regions you serve?

10. Your organization is [non-profit] [governmental] [commercial]? (Choose whatever the record states)

11. What are your business (service) hours?

12. Do you have separate hours for particular services, such as HIV testing?

13. Do you require appointments?

14. Are fees charged for services?

15. Is your [key staff title and name] still __________________?

16. Do you offer services in any other language other than English?

17. Are there any restrictions on eligibility (for services)? Such as residency, income level, age, etc.

18. I’m going to read the services we have listed for your organization, please tell me if I should delete any of them.

19. What other services do you provide that I didn’t mention? (Read headings of categories.)

20. Do you provide HIV-antibody testing? Is it anonymous and/or confidential? Oral or blood draw? Any rapid testing? If so, what type?

21. Do you offer free HIV testing?

22. Do you offer pre- and post-test counseling? Is it anonymous and/or confidential?

23. Do you have a company newsletter that is available to the public?

24. What is (are) your main target population(s)? (Audiences)

25. Thank you and please contact us at (800) 458-5231 with any questions or visit our website at www.cdcnpin.org.