Adult Targeted Survey Screener

Adult Targeted Surveillance Survey Recruitment Screener

Form Approved

OMB No. 0920-xxxx

Exp. Date xx/xx/xxxx

Selection Check-List

Thank you for your interest in participating.

Only One Adult Lives Here? If you are the only adult who lives at <<sampled address>>, then you qualify. Please take part in our study by calling << toll free # >> and mentioning ID number << CASEID-A>> or by filling out and returning the enclosed consent form, incentive form, and questionnaire.

More than One Adult Lives Here? If more than one adult lives in your household, then we need your help to randomly select one person to complete the survey, by using the checklist below.

The one person who completes the survey booklet must:

• Be an adult (18 years old or older).

• Currently live at {fill address}, as his or her primary residence.

• Please do not include anyone who is away at school or away in the military, or anyone who is visiting temporarily. Just include adults who currently live in the household.

• Have the birthday that’s coming up next.

• We can only invite one adult to participate but we want all adults to have an equal chance of being invited. Choosing the adult with the birthday coming up next is like picking names out of a hat.

The person who fits the description listed above is invited to participate. Participation is easy and may be completed in one of two ways:

• Call << toll free # >> and mention ID number << CASEID-A>> .

- OR –

• Fill out and return the enclosed questionnaire, consent form, and incentive form.

Public reporting burden of this collection of information is estimated to average 2 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-xxxx)