Enrollment

Form Approved

OMB Approval No. 0920-1050

Expiration Date: 02/18/2018

StopAnthrax™ Jurisdictional Pilot Test

Enrollment Questions

Note: The information participants provide is part of an exercise and not true information.

1. What is your first name (or nickname)?

2. What is your ZIP code?

3. Are you pregnant? Reply Yes or No

4. Do you have a child or children also taking medication for anthrax? Reply Yes or No

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 (0920-1050).

 

Pilot Test Enrollment Questions 1