Form Approved

OMB No. 0923-0056

Exp. Date 7/30/2020

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

Instructions:

• Please complete this paper survey and return it in the stamped addressed envelope.

OR

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

[INSERT NAME]

Please correct the information below if it is not your current address:

[INSERT STREET ADDRESS]

[INSERT CITY, STATE, ZIPCODE

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 (0923-0056).

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

Please fill out the information below if you are interested in participating in the Milwaukee Angler Project. (This information will be used for this project only.)

Email address: ____________________________________________

Telephone numbers where we can reach you:

Cell: (_______) ________ - ______________ Can we send you text messages? Yes No

Home: (_______) ________ - ______________

Work: (_______) ________ - ______________

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 may contact you in the next week or two if you are a good fit for this project.

Map of the waterbodies of interest