Form Approved
OMB No.: 0920-XXXX
Exp. Date: _____________
A Screener FOR PARENTS
“Learn thE signs. Act Early.”
Screener
Survey administrator (script):
Would you be willing to complete a survey for us? It should only take 10 minutes to complete.
Do you have a child who is 5 years old or younger?
If yes -> Continue to next question
If no -> Thank and end
What language would you prefer for a survey?
English & Spanish -> Continue with English or Spanish survey
If other -> Thank and end
Public reporting burden of this collection of information is estimated to average 3 minutes 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-11EX).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Title | LTSAE |
| Author | bzheng |
| File Modified | 0000-00-00 |
| File Created | 2021-01-31 |