[Letterhead with state BCCCP program logo]
Dear [NAME],
The Centers for Disease Control and Prevention (CDC) and NORC at the University of Chicago are doing a study on women’s health services. They would like to send you information on the study, but will need your contact information. We will not share that with them unless you agree.
If you would like to learn more, please fill in the information below. You can return the bottom half to us using the enclosed postage-paid envelope.
This is voluntary. You do not have to participate or share your contact information. Your services will not be affected if you do not wish to share your information or if you are not interested in their study.
Sincerely,
[State BCCCP Program Director Name]
[State BCCCP Program Director Signature Line (if applicable)]
[State BCCCP Program Director Address]
[State BCCCP Program Director Phone]
[State BCCCP Program Director E-mail Address]
----------------------------------------------------------- TEAR HERE ---------------------------------------------------------------
By returning this form, you agree to share your contact information with CDC and NORC at the University of Chicago for a study on women’s preventive health services. NORC will be conducting the study on behalf of CDC.
Please fill in the information below and return using the enclosed postage-paid envelope.
NAME ____________________________________________ PHONE _(____)_____-________
ADDRESS __________________________________________
ADDRESS2 _________________________________________
CITY _______________ STATE ________ ZIP _____________
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Donna Shaw |
| File Modified | 0000-00-00 |
| File Created | 2021-01-22 |