Form 1 Poison Help Survey Screener

OMB Number 0915-XXXX

Expiration Date: _________

Poison Help

GENERAL Population Survey Screener

S1. Hello, this is (INTERVIEWER) and I’m calling for the Health Resources and Services Administration, HRSA, about a research study. Are you a member of this household and at least 18 years old?

YES 1 (GO TO S3)

NO 2 (GO TO S2)

PROBABLE BUSINESS 3 (GO TO S3)

S2. May I please speak with a household member who is at least 18 years old?

AVAILABLE 1 (GO TO S1)

NOT AVAILABLE 2 (GO TO RESULT, CALLBACK APPT.)

THERE ARE NONE 3 (GO TO THANK2)

S3. Is this phone number used for…

Home use, 1 (CONTINUE)

Home and business use, or 2 (CONTINUE)

Business use only? 3 (GO TO THANK1)

BOX 1

Go to extended interview.

THANK 1. Thank you, but we are only interviewing in residences.

THANK 2. These are all the questions I have at this time. Thank you very much for your time.

Public Burden Statement:

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.  The OMB control number for this project is 0915-XXXX.  Public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, and completing and reviewing the collection of information.  Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to:  HRSA Reports Clearance Officer, 5600 Fishers Lane, Room 10-49, Rockville, MD 20857.