OMB No: ???: Exp Date: ???
_____________________
|
Strongly Disagree |
Disagree |
Neutral |
Agree |
Strongly Agree |
|
O |
O |
O |
O |
O |
|
O |
O |
O |
O |
O |
|
O |
O |
O |
O |
O |
|
O |
O |
O |
O |
O |
FOR STUDY USE ONLY |
|||
Date Interviewed |
Month Day Year |
Interviewed by |
|
Public
reporting burden of this collection of information is estimated to
average 1 minute 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 Clearance Officer; 1600 Clifton Road
NE, MS D-24, Atlanta, Georgia 30333; ATTN: PRA (???).
File Type | application/msword |
File Title | Demographic Survey |
Author | Robert McKeown |
Last Modified By | fps8-su |
File Modified | 2007-03-19 |
File Created | 2006-10-23 |