Form Approved
OMB No. 0923-XXXX
Exp. Date xx/xx/20xx
Attachment 4
Validation Questions
Q1: |
Were you ever told by a health professional that you might have ALS or Lou Gehrig’s disease? |
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a. Yes (Go to Q2) |
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b. No (Go to Q3) |
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Q2: |
Were you clinically diagnosed with ALS? |
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a. Yes (Go to Q5) |
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b. No (Go to Q3) |
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Q3: |
Is there another diagnosis that you have been given by a health professional? |
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a. Yes (Go to Q4) |
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b. No (Go to Q5) |
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Q4: |
What was the diagnosis? |
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a. Possible ALS (not yet determined/diagnosed) (Go to Q5, then Q6) |
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b. Primary lateral sclerosis (Go to Q5, then Q6) |
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c. Progressive bulbar palsy (Go to Q5, then Q6) |
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d. Progressive muscular atrophy (Go to Q5, then Q6) |
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e. Other (please list) (Go to Q5, then Q6) |
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Q5: |
Have you been seen by a neurologist? |
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a. Yes (Go to Q6 if Q2 = Yes, or Q3 = Yes) |
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b. No (Go to Q6 if Q2 = Yes, or Q3 = Yes) |
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Q6: |
What was the date of your diagnosis? |
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__ __/__ __/__ __ __ __ |
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M M D D Y Y Y Y |
Public reporting burden of this collection of information is estimated to average 49 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed and completing and reviewing the data 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 Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333; ATTN: PRA (0923-XXXX).
| File Type | application/msword |
| File Title | Attachment 4 |
| Author | wek1 |
| Last Modified By | wek1 |
| File Modified | 2009-11-23 |
| File Created | 2009-11-23 |