MN Participation Record

Attachment 5g (MN 7.2) Participation Record FORM APPROVED

6.1 reading level without burden statement OMB No. 0923-XXXX

Expiration Date: MM/DD/ YYYY

Fond du Lac

^{Human Services}

Fond du Lac Community Biomonitoring Study

Participation Record

By checking the box or boxes and by signing below, you state that you received this amount in gift cards.

Your signature will only be used to show you received the gift cards.

Your signature will not be used for any other reason.

I received $25 in gift cards as thanks for doing the blood draw and urine collection.

I received $25 in gift cards as thanks for doing the interview and body measures.

I received $25 in gift cards as thanks for completing both parts of the study.

_________________________________________ ____________________________

Signature Date

Study ID Total Gift Card Amount: 25 50 75

_____________

Staff initials

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).

Appendix 7.2. page 1