Form Approved
OMB No. 0920-0896
Exp. Date XX/XX/XXXX
Attachment 3d
Community-based Organization (CBO) Monitoring and Evaluation Project of WILLOW (CMEP-WILLOW)
180-Day Secure Data Network (SDN) Submission
This form identifies the monthly submission of completed 180-day follow-up surveys via an SDN submission of the Questionnaire Development System (QDS) Data Warehouse Manager file which is a flat data file produced by the QDS software.
Grantee_______________________________________________________
Date grantee submitted the 180-day survey data to CDC via the SDN __/__/____.
Public reporting burden of this collection of information is estimated to average 5 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0896).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | CDC User |
| File Modified | 0000-00-00 |
| File Created | 2021-01-27 |