Example Screening Form 30MAR2017

Attachment G

Example Screening Form

Form Approved

OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Example screening tool introduction for investigation that includes collecting survey data and environmental samples:

Before asking the screening questions:

Hello, my name is {SAY NAME}. We are doing an investigation for the National Center for Environmental Health, or NCEH, at the Centers for Disease Control and Prevention and [name of requesting entity]. The investigation is to help us understand the potential exposures from using private wells for drinking water. I would like to ask you a few questions to see if you are eligible to be in our investigation. May I ask you a few short questions? I will only take a few minutes of your time.

Example screening tool introduction for investigation that includes collecting survey data and biologic specimens:

Before asking the screening questions:

Hello, my name is {SAY NAME}. We are doing an investigation for the National Center for Environmental Health, or NCEH, at the Centers for Disease Control and Prevention and [name of requesting entity]. The investigation is to help us understand the potential exposures from using private wells for drinking water. I would like to ask you a few questions to see if you are eligible to be in our investigation. May I ask you a few short questions? I will only take a few minutes of your time.

CDC estimates the average public reporting burden for this collection of information as 6 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 Information Collection Review Office, 1600 Clifton Road NE, MS D-74, Atlanta, Ga. 30333; ATTN: PRA (0920-xxxx).

Sample screening questions

1. Do you have a private well? (By “well,” we are referring to any means of getting water from the ground, including dug, bored, or drilled wells).

• Yes

• No

If no: Thank you for your time, but we need people who get their drinking water from private wells for our investigation.

2. Are you at least 18 years of age?

•  Yes

•  No

If no: Thank you for your time, but we need adults who get their drinking water from private wells for our investigation.

3. Do you currently use your private well for drinking or cooking?

• Yes

• No

• I don’t know

If no or I don’t know: Thank you for your time, but we need people who get their drinking water from private wells for our investigation.

Thank you. You are eligible to be in our investigation. Now, I’d like to tell you more about it.

Go to consent form.