Form 0920-1030 Contact Information Verification

Attachment B.1: Contact Information Verification

Advance Package Call Document

Form Approved

OMB No. 0920-1030

Exp. Date 04/30/2020

NOTICE – CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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 (0920-1030).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you.

VERIFY CONTACT INFORMATION

• Hello, my name is ­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­…………… I have some information that I would like to mail to the following state government representative [name]. May I please verify this person’s name and title?

• I have the name of this state government representative as …………… SPELL IF NECESSARY. Is this correct?

• I have the address of the state government representative as _……………. Is this correct? Is there a separate mailing address you would like to give me?

• The number I called is [xxx-xxx-xxxx]. Is this the correct number to reach…………… REPEAT TO VERIFY

• What is [state government representative’s] email address? SPELL ALOUD TO VERIFY.

• Thank you. I will put this information in the mail within 2 business days. Have a good day. Good bye.

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