Survey for Refusals

Attachment 3.4

Anniston Community Health Survey: Follow-up Study and Dioxin Analyses

Survey for Refusals

Flesch-Kincaid Grade Level 4.9

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx xx/xx/20xxExDaxx/xx/20xx

Exp. Date xx/xx/20xx

Non-participant Information

IF THE RESPONDENT IS WILLING, ASK THE FOLLOWING QUESTIONS:

1. Are you [Mr./Ms.] _____?

1…….YES

2…….NO

(If YES, proceed to next question)

2) Did you participate in the original Anniston Community Health Survey a few years back?

1…….YES

2…….NO

8.……DK

9.……REF

3) Could you please tell me the reason why you don’t want to participate in the current survey?

(Refer to FAQ’s to respond to specific reasons)

____________________________________________________

Public reporting burden of this collection of information is estimated to average 1 minute 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0923-XXXX).

4) Would you say that in general your health is excellent, very good, good, fair, or poor?

01 . . . EXCELLENT

02 . . . VERY GOOD

03 . . . GOOD

04 . . . FAIR

05 . . . POOR

88 . . . DK

99 . . . REF

Note:

DK – Don’t know.

REF – Refused.