Worker Notification Survey

Form Approved

OMB No. 0920-0953

Exp. Date 12/31/15

Questions for the response card to go with the initial letter

More detailed information about this study is available on the Internet and by mail. The information content is the same in both formats.

Do you plan to get more detailed information from the website?

Yes

No, because [Please check all that apply.]

I do not use a computer.

I already received enough information from the letter.

I am not interested.

This information does not apply to me.

Other ___________________________________

Any comments on getting information from the website? _________________________________

Would you like us to mail you more detailed information from the website?

Yes Please mail it to me (Detach, complete and mail-in the request card included)

I will call or email to request the information.

I have already called or emailed to request the information.

No, because [Please check all that apply.]

I will look it up on the Internet.

I already received enough information from the letter.

I am not interested.

This information does not apply to me.

Other ___________________________________

Any comments on receiving information in the mail? __________________________________________

Are you the person to whom the letter was sent?

Yes  Are you still working at [company]? Yes No

How old are you? ______________

Are you a woman or man? Woman Man

No  I am

the spouse

other family member

a friend of the person

Other ________________________________

Please tell us what you thought about the letter and anything else you would like us to know. Comments and suggestions are welcome. Please do not provide your name or other information that would identify you. If you would like us to contact you, please email [email protected] ­­­­­:_________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Public reporting burden of this collection of information is estimated to average 10 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 (0920-0953).