Health Department Roster Form

Please Read: The National Environmental Health Association, Baylor University, and the Centers for Disease Control and Prevention are collaborating on a groundbreaking initiative--Understanding the Needs, Challenges, Opportunities, Vision and Emerging Roles in Environmental Health (UNCOVER EH). The purpose of this initative is to understand and describe the environmental health profession, areas of practice, and identify workforce and practice needs. In order to this, we have put together a survey. We would like to have as many members of the public health department environmental health workforce complete the survey. We would like your help to compile a list of the names and business email addresses of all the environmental health workers within your health department. Participation in this effort is completely voluntary. The information you provide on this sheet will only be used to recruit and contact UNCOVER EH survey participants and for no other purpose. The information you provide will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release the identity of any environmental health workers in any CDC reports. Upon completing this roster, please email to [email protected]. If you have questions about this roster, please send an email to [email protected]
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-xxxx).
Environmental Health Professional Name	Email Address