Web Survey of Asthma Program Evaluators

Form approved:

OMB No. 0920-0879

Expiration Date 03/31/2014

ATTACHMENT – B: Data Collection Instrument - Web version

Part 1

SURVEYS OF STATE and TERRITORIAL ASTHMA PROGRAM EVALUATORS

ATTACHMENT – B: Data Collection Instrument - Web version

Part 2

Public reporting burden of this collection of information is estimated to average 20 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 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, Georgia 30333; ATTN: PRA (0920-0879).