Contact Information - English

Form Approved
OMB No. 0920-XXXX
Exp.: XX/XX/20XX
Attachment 17 – Contact Information Form
Thank you for providing your child’s contact information. The findings from the survey will help current adults
who were born with heart conditions and the future lives of children born with heart conditions.

Your current name (First Last):
Your name at time of child’s birth (First Last)
Child’s current name (First Last):
Your child’s name at birth (First Last)
Child’s phone number (xxx)-xxx-xxx:
Child’s address:

Number and Street

Apt Number

City, State Zip Code
Child’s email address:

Public reporting burden of this collection information is estimated to average 2 minutes, including completing and reviewing
the collection of information. An agency may not conduct or sponsor, and a person is not required to respond to a
c o l l e c t i o n 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333: ATTN: PRA (0920-XXXX).