Screening for the Women's Health Survey

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Form Approved
OMB No: 0920-xxxx
Exp. Date: xxJxxJxx
Welcome to CDC's Women's Health Study Survey!
The survey is being conducted to help the Centers for Disease Control and Prevention (CDC) better
understand the health of women in your metropolitan area, identify effective strategies to address
women's health issues, and improve the health of women around the nation. Your participation in
this survey will help CDC better communicate with women about their health. Your participation is
very important and is completely voluntary. You may refuse to answer any of the survey items you
wish. We anticipate it should take no more than 20 minutes to complete the survey. If you need to
stop the survey and come back to it later, you may exit the survey and log in again later to complete
it. All of your responses will be saved.
Please call «PHONE», visit «WEBLINK TO INFORMATION SHEET», or email «EMAIL» if
you have any questions or want more information. If you have technical problems or questions
about the survey items, please contact [NAME] at Battelle at [PHONE] or [email]. If you agree to
participate and are ready to begin the Women's Health Study Survey, please click on the Agree to
Participate and begin survey link below to proceed. Thanks again for your time and input! Please
complete and submit your survey responses on or before [DATE].

Public Reporting burden of this collection of information varies from 3 to 20 minutes with an average of average 20 minutes per response,
including the time for reviewing instructions. searching existing data sources, gathering and maintaining Ihe dala needed, and completing
and reviewing the collection of information. An agency may noi conduci or sponsor, and a person is not required to respond to a collection
of information unless il displays a currently valid OMB conlrol number. Send comments regarding this burden estimale or any other aspect
of this collection of information. including suggestions for reducing this burden to COC/ATSOR Reports Clearance Officer. 1600 Clifton
Raad NE. MS 0-74, Atlanta, Georgia 30333; AnN: PRA (0920-xxxx).

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Agree lo participate and begin survey

C,) Decline lo participate

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Near which city do you live?

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Cincinnati

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Las Vegas

(_) Milwaukee

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San Antonio

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Other

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How long have you lived at this area?

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Less than 6 months

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6·12 months

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More than a year

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How old are you?

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What is your gender?

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Female

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Male

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Transgender

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Other

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We thank you for your time spent taking this survey.
Your response has been recorded.

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