Screener

Form Approved

OMB No. 0920-0940

Exp. Date 03/31/2018

Recruitment Screener

1. Name, Address, Telephone Number, Email Address

2. Are you of Hispanic, Latino/a, or Spanish origin? Yes, No

3. Would you prefer to be interviewed in English or Spanish? English, Spanish

4. Gender Male, Female, Other

5. Age under 18, 18-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70+

6. Role in the business Owner, Manager, Both

7. For how long have you worked in the restaurant industry? (Select only one)

   1. Less than 5 years

   2. 5-10 years

   3. 11-20 years

   4. 21-30 years

   5. More than 30 years

8. Business Classification: (Select only one)

   1. Privately-owned restaurant with table service

   2. Franchise restaurant with table service

   3. Privately-owned restaurant/café (seating but no table service)

   4. Franchise restaurant/café (seating but no table service)

   5. Privately-owned retail restaurant/eatery (no seating)

   6. Franchise retail restaurant/eatery (no seating)

   7. Food Truck

   8. Caterer

   9. Wholesaler of prepared foods

9. What is the size of your business? (Select only one)

   1. 1-4 employees

   2. 5-9 employees

   3. 10-19 employees

   4. 20-49 employees

   5. 50-99 employees

   6. 100-249 employees

   7. 250+ employees

Public reporting burden of this collection of information is estimated to average 3 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing 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 (0920-0940).