Medical Testing

Attachment 3: Medical Testing Mock Form

Form Approved

OMB NO: 0920-0888

Exp. Date: xx/xx/20xx

Medical testing

This is a mock form that represents the medical testing that will be taking place during this study. The medical testing will include an oral temperature reading, two nasal swabs and one oral swab collection. Additionally, participants will be asked to breathe out completely, breath in as much as possible, then seal their lips around a disposable mouthpiece, and cough. They will be asked to cough hard using as much of the air in their lungs as they can. We will record the sounds that the coughs make, and we will collect the airborne particles produced while coughing. Participants will be asked to provide a total of six coughs.

Public reporting burden of this collection of information is estimated at 30 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/Information Collection Review Office, 1600 Clifton Road, NE, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-0888).