Fax Cover Sheet to Determine if Mailing was Received - P

Protocol Appendix F – Fax Cover Sheet to Determine if Mailing was Received

Form Approved

OMB No. 0923-XXXX

Exp. Date xx/xx/20xx

[ON PROJECT FAX COVERSHEET]

Promotion of the National ALS Registry

to Non-referral Centers

Fax

	To: Dr. XXXXX		From:
	Organization:		Organization: McKing Consulting Corporation
	Phone:		Phone:
	Fax:		Secure, Toll Free Fax:
	Date:		Number of Pages:
Comments:

The Agency for Toxic Substances and Disease Registry (ATSDR), a public health agency within the U.S. Department of Health and Human Services, awarded McKing Consulting Corporation (McKing) a contract to promote the National ALS Registry (Registry) to non-referral center neurology practices in your state. The objectives of this pilot project are to conduct educational and promotional outreach activities to inform neurologists and their staff about the Registry, to encourage them to inform their patients about the Registry, and to increase Registry self-enrollment among persons with ALS.

We recently mailed several Registry promotion materials to your office via the US Postal Service at the above address. Members of our staff have called your office to determine if you have received this mail. Please indicate on this letter if your practice did receive the National ALS Registry promotion materials and fax it back to (855) 598-7485 (toll free).

Yes, I did receive the National ALS Registry promotion materials.

No, I did not receive the National ALS Registry promotion materials.

If you have questions about this project, please contact Heather Jordan at (609) 613-6930/[email protected] or Lindsay Rechtman (404) 683-4394/[email protected].

Thank you in advance for your support of National ALS Registry Promotion Project.

Sincerely,

Wendy E. Kaye, PhD

Project Director, National ALS Registry Promotion Project

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).