Permission to Contact Potential Participants

Form Approved

OMB No. 0920-XXXX

Exp. Date XX/XX/XXXX

A Study of Primary and Secondary Prevention Behaviors

Practiced Among Five-Year Survivors of Colorectal Cancer

List of Potential Study Participants for: PHYSICIAN NAME: [auto-filled by contractor]

Instructions: Please review this list and notify CDC’s recruitment contractor, the Public Health Institute (PHI), if you feel that one or more of the named individuals should NOT be asked to participate in the study. If you feel it is OK for study staff to contact the listed patient(s) for this study, you do not need to respond. Exclusion criteria for the study are included only to facilitate the identification of individuals who should not be contacted by study staff.

DO NOT RETURN THIS FORM to PHI.

Physician’s Point

of Contact at PHI: (Name) at (toll-free phone number)

	Patient should not be contacted for one or more of the following reasons:
Patient Name or Identifier [auto-filled by contractor]	Patient in Active Treatment	Patient Deceased	Patient Moved or Lost to Follow-Up	Language Barrier	Other
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Public reporting burden for this collection of information is estimated to average 13 minutes per response, including 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 Reports Clearance Officer, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).