Hazardous Substances Emergency Events Surveillance Data Request Form

OMB NO.: 0923-0008
EXPIRATION DATE: 05/31/2008

Hazardous Substances Emergency Events Surveillance (HSEES)
Service or Material Request Form
* Indicates required information
Requestor Information:
* Date Submitted: ____/____/____

* Date Needed: ____/____/____

* Name: _____________________________________________
Title: ______________________________________________
* Address: ___________________________________________________________
* City: ________________________________* State: ______ * Zip: ______-____
Phone: __________________________

Fax: ____________________________

* E-mail address: ______________________________________________

Service or Material Requested (check off what is needed)
____ HSEES public use dataset (to do your own data analysis)
__ Please mail me a CD
__ I will download from this website
____ Custom Data Request (describe exactly what data is needed)
__________________________________________________________________
__________________________________________________________________
____ HSEES brochure

(number of copies) _____

____ HSEES Report Year(s) ______ Number of copies _____
____ HSEES Protocol
____ HSEES Data collection Form and Training Manual
____ Journal Article: Lead Author _________________ Year__________
Title or Topic _______________________________________________________
____ Clearance of HSEES-related materials that will be disseminated
____ Other (specify) ______________________________________________________

OMB NO.: 0923-0008
EXPIRATION DATE: 05/31/2008

Will this information be disseminated in any way (i.e. as part of a fact sheet, report,
presentation, poster, journal article)
__ Yes, redistributed, as is (please complete rest of form)
__ Yes, as part of something new (please complete rest of form)
__ No (Thanks, you are finished)
PLEASE COMPLETE ALL OF THE INFORMATION SO THAT WE MAY
CONTINUE TO JUSTIFY THIS PROGRAM AND PROVIDE THESE SERVICES
* Target Audience type(s) _________________________________________________
(i.e., EMTs, Industry Safety Personnel
* Approximate Audience Number __________________________________________
(i.e., copies distributed, attendees at the conference, or hits on website)
Intended purpose for requested materials (check off all appropriate)
____ Internet Site

(website address or name) __________________________

____ Fact Sheet

topic ___________________________________________

____ Report

topic ___________________________________________

____ Journal Article

topic ___________________________________________
Submitting to: ___________________________________

____ Newsletter

topic __________________________________________
Submitting to: ___________________________________

____ Poster or presentation

topic __________________________________________

for a conference,

Name of Conference _____________________________

meeting, etc.

Date____/____/____

_____ General awareness information on the program

____ Other

(specify) _______________________________________

Is this an HSEES approved prevention outreach activity

yes no

If not submitting online, submit to Casetta Simmons, ATSDR/DHS/ESB, 1600 Clifton Road, N.E.,
Mailstop E-31, Atlanta, GA 30333, Fax to 404-498-0077, E-mail [email protected]

_____________________________ For Official Use Only ______________________________
ID # __________ Date Received ____/____/____ Date Completed ____/____/____Initials____