Primary Care Provider Opt-Out Card

Attachment 9: PCP Survey Opt Out Card

Form approved

OMB No. 0920-xxxx

Expiration xx/xx/xxxx

ID:

Please return this card if you do not wish to participate

in the survey about the diagnosis and referral of hematological malignancies.

We will not attempt to contact you further

if you return this card to us.

Thank you.

Public reporting burden of this collection of information is estimated to average 2 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining 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, Georgia 30333; ATTN: PRA (0920-XXXX)