Contact Information Verification

Attachment D.1: Contact Information Verification

Form Approved

OMB No. XXXX-XXXX

Exp. Date __xx/xx/20xx

NOTICE – Public reporting burden for the contact verification is estimated to average 5 minutes per response. 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, MS D-74, Atlanta, GA 30333, ATTN: PRA (XXXX-XXXX).

Assurance of Confidentiality – All information which would permit identification of an individual, a practice, or an establishment will be held confidential, will be used for statistical purposes only by NCHS staff, contractors, and agents only when required and with necessary controls, and will not be disclosed or released to other persons without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 USC 242m) and the Confidential Information Protection and Statistical Efficiency Act (PL-107-347).

VERIFY CONTACT INFORMATION

• Hello, my name is ___________________ . I have some information that I would like to mail to the following state government representative [name]. May I please verify this person’s name and title?

• I have the name of this state government representative as ______________________ SPELL IF NECESSARY. Is this correct?

• I have the address of the state government representative as _______________________. Is this correct? Is there a separate mailing address you would like to give me?

• The number I called is [xxx-xxx-xxxx]. Is this the correct number to reach ______________? REPEAT TO VERIFY

• What is [state government representative’s] email address? SPELL ALOUD TO VERIFY.

• Thank you. I will put this information in the mail within 2 business days. Have a good day. Good bye.

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