WV Flood 2016 CASPER Referral Form

Form Approved

OMB No. 0920-1036

Exp. Date: 12/31/2017

Community Assessment for Public Health Emergency Response after West Virginia Flood, June 22 – 29, 2016

Confidential Referral Form

Date: ___/__/____ Time: ___:__

Cluster No.: ____

Survey No.: _____

Interviewer’s Initials: _____

Name: _________________________________________________

Address: _______________________________________________

Home telephone: ______ - _____ - _______

Cell phone: _____ - ____ - _______

Summary of Need:

Referral Made: Yes No

Referred to: _______________________________________

CDC estimates the average public reporting burden for this collection of information as approximately 5 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 collection of information unless it displays a currently valid OMB control number. Send comments regarding this burden statement or any other aspect of this collection of information, including suggestions for reducing this burden to CDC/ ATSDR Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-1036).