Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

Attachment 5b. Eligibility Screening Survey for Licensed Anglers (paper)

[Name and address from fishing license]

[Date of birth from fishing license]

Instructions:

• You can fill out this form or complete it online at [LINK TO ONLINE SURVEY]. If you fill out this form online, you do not need to return this survey in the mail.

• Please read statements #1-4 below. Mark the box at the right if the statement is true.

• Please correct your name, address, or date of birth above if they are wrong.

• Return the form in the stamped addressed envelope.

ATSDR 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 (0923-17IY).

1. Yes, I currently live at the address above. 

2. Yes, I have lived at this address for one year or longer. 

3. Yes, I am a male OR I am a female who is not currently pregnant. 

   

   Please look at the enclosed maps and read this list of bodies of water. We want to know if you have eaten fish that were caught in any of these rivers, creeks, lakes, or ponds.

   • Cedar Creek

   • Milwaukee River

   • Little Menomonee River

   • Menomonee River

   • Kinnickinnic River

   • Lincoln Creek

   • Near-shore waters of Lake Michigan near downtown Milwaukee

4. Yes, in the past 12 months, I ate at least one fish meal that was caught in the bodies of water listed below. 
   
   

If you checked all four boxes above, please fill out the information below. (This information will be used for this project only.)

Email address: __________________________________________________

Telephone numbers where we can reach you:

(_________) _________ - ______________ home/work/cell (circle one)

(_________) _________ - ______________ home/work/cell (circle one)

(_________) _________ - ______________ home/work/cell (circle one)

Check the best days and times to reach you by telephone.

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
Morning
Afternoon
Evening

Thank you for filling out this survey and returning it to us. A staff member from this project may contact you in the next week or two if you are a good fit for this project.

Map of the waterbodies of interest