Form 4 National Youth Physical Activity and Nutrition Study Stu

E. Student Contact Form for 24-Hour Dietary Recall

Form Approved

OMB No.: 0920-XXXX

Expiration Date: XX/XXX/XXXX

National Youth Physical Activity and Nutrition Study

Student Contact Form

Please complete this form so that we may contact you for an interview. Be sure you include your area code with your telephone number.

Please print clearly.

First and Last Name:
Home Telephone Number:
Telephone Number of Another Place Where You May Stay:
Cell Phone Number:
Best Times to Try to Reach You:
Email Address:

Public reporting burden for this collection of information is estimated to average 2 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-XXXX).