App C_Recruitment Web Screener

Appendix C

Form Approved

OMB No. 0920-0822

Exp. Date: 6/30/2016

Public Reporting burden of this collection of information is estimated at 5 minutes 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 Reports Clearance Officer, 1600 Clifton Road NW, MS D-74, Atlanta, GA 30333; Attn: PRA (0920-1009).

Screen: Introduction

Screen: Question 1

Screen: Question 2

Screen: Question 3

Screen: Question 4

Screen: Question 5

Screen: Question 6

Screen: Question 7

Screen: Introduction 2

Screen: Question 8

Screen: Question 9

Screen: Question 10

Screen: Eligible Closing

Screen: Ineligible Closing