Form 0920-1009 Attachment A_Screener

ATTACHMENT A: SCREENER

Form Approved
OMB No: 0920-1009
Exp. Date: 3/31/2017

Public Reporting burden of this collection of information is estimated at 3 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 NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-1009).

1. Does your organization use CDC HEADS UP concussion education materials?

   1. YES (Continue)

   2. No (End Survey)

   3. Unsure (End Survey)

2. What best describes the scope of your organization?

   1. National

   2. Regional

   3. Local

   4. Other (please explain)

2a. If your organization is a regional or local organization, is it affiliated with a national organization?

• Yes

• No

3. Which of the following best describes your organization, department, institution or agency? (Select ALL that apply)

   1. Local government (e.g., city, county or other)

   2. State government

   3. Professional membership association (Please specify area of focus: youth, health, sports, education, or parenting)

   4. Nonprofit organization

   5. Private company

   6. Sports organization or league (please specific sport: _____________________)

   7. Hospital or clinic

   8. Private medical practice

   9. Health care-related organization such as health insurance company

   10. Youth-serving organization

   11. School system (Please indicate: elementary school, middle school, or high school)

   12. School administration

   13. Education-related organization (e.g., Parent Teacher Association, tutoring service, other education organization)

   14. Faith-based organization

   15. Other:

4. What is the size of your organization (including staff)?

   1. Small (less than 100)

   2. Medium (100-1,000)

   3. Large (More than 1,000)

5. Does your organization have members or affiliates?

   1. Yes; Specify type of members/affiliates:______________________________________

   2. No

6. What is the zip code of your office location?

7. Which groups does your organization serve? (Check all that apply)

   1. Parents

   2. Coaches

   3. Youth/ young athletes

   4. School professionals

   5. Health care providers

   6. Other: __________________________________