Contact Information Form for Burmese Immigrants and thei

Biomonitoring of Great Lakes Populations Program III

Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

Attachment 7a. Contact Information Form for Burmese Immigrants and their Descendants

Milwaukee Angler Project

Participant Contact Information Form

1. What is your full name?

First: ________________________ Last: __________________________ Middle Initial: ___

2. What is your phone number?

Home: _____________________

Cell: _____________________

Do not have a phone number

3. What is your email address?

Email address: ______________________________

Do not have an email address

4. What is your street address?

Line 1: ________________________________

Apartment number:______________________

City: __________________ State: ____ Zip Code: _______

5. Is this the same address where you get your mail delivered?

Yes

No

If no – What address is your mail delivered to?

Line 1: ________________________________

Apartment number:______________________

City: __________________ State: ____ Zip Code: _______

(Continued on next page)

ATSDR estimates the average public reporting burden for this collection of information as 5 minute 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).

6. What language are you most comfortable speaking? This will help us decide which interpreter you will work with today during your visit.

English

Burmese

Chin

Karen

7. What language are you most comfortable reading? This will help us decide what language your results letters should be in.

English

Burmese

Karen