CDC EHDI Hearing Screening and Followup Survey (HSFS)

Attachment 4A

Form Approved

OMB No. 0920-0733

Exp. Date XX/XX/XXXX

CDC EHDI Hearing Screening and Follow-up Survey (HSFS) Directions

Internal Use Only

Directions

Please complete the following survey with the requested data for infants born between January 1, XXXX and December 31, XXXX.  The survey is divided into several sections, which include Hearing Screening data, Diagnostic data, Early Intervention data, Type/Severity data, and Demographic data. Please enter any comments and/or caveats about the data reported in the Comments section at the end of the survey. 

Note: Data cannot be manually entered into fields highlighted in yellow. Data for these yellow fields will automatically be calculated based on the data entered into the non-highlighted fields. These calculated values will appear in the yellow boxes when you select the "Calculate Totals" button near the top of each page.

If you have any questions please contact Marcus Gaffney at [email protected] or (404)498-3031.

The 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 (0920-0733)