EARS registration form

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Form Approved OMB No. 0920-xxxx Exp xx/xx/xx You must register to download EARS. The registration information you provide will be used by the EARS Team to understand our user base so we may improve EARS. We may also use your e-mail address, in rare instances, to notify you of updates or technical issues and solutions.
*required field
Section 1: Please provide the business contact information for the person who will be using EARS.
Salutation:
First Name: *
Last Name: *
Job/Position Title:
Business/Work Email Address: *
Business/Work Phone:
Section 2: Please tell us about your business organization.
Organization Name: *
Organization Country: *
Organization State/Territory: *
Organization Type: *	US Government            Local/City/County            State/Territory/Tribal            National/Federal Foreign Government Non-Governmental Organization Hospital/Healthcare/Laboratory Academic institution Corporation/Business Other
Section 3: What type of data do you plan to use EARS for?
	Education Employee/School Absenteeism Environmental/Natural resources Health/Medical care Veterinary Industrial/Commercial Pharmacy/Over the Counter Drug Sales Judicial Law enforcement/911 Military Other
Section 4: Please characterize your prior methods and frequency of EARS use:
Methods: *	I have never used EARS before I use the EARS software as is or have made slight modifications to customize it I only borrowed portions of the program/code
Frequency: *	I have never used EARS before Infrequent user (less than once per month) Occasional user (approximately once per month) Regular user (One or more times per week)
Section 5: We are interested in tailoring EARS to fit your needs. If you have used the EARS before please answer the following questions. (optional)
Please tell us what you like most about EARS:
Please tell us what you like least about EARS:
Please provide suggestions for improvement:
If you would rather talk to someone about EARS to tell us your recommendations and notify us of problems and suggestions please let us know via [email protected] and someone from the EARS Team will call you.
Thank you for completing the registration questions. Submit your registration information to download EARS.

 

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the 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 current 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).

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