Form 0920-0879 STD Program Manager Referral Form

Form Approved OMB No. 0920-0879 Expiration Date 01/31/2021

Attachment B: STD Program Manager Referral Form

Dear [Program Manager],

The Cloudburst Group, LLC is currently working with the CDC to assess the value, need, gaps, and impact of strategic partnerships between territorial and local health departments (LHD) with the highest STD morbidity (syphilis, chlamydia and gonorrhea) and their STD clinical partners.

We have attached the web-based assessment so that you are familiar with the types of questions on the assessment of local STD programs’ strategic clinical partnerships. We are particularly interested in attracting individuals such as program managers who are responsible STD program management and have knowledge of STD clinical partnerships.

Please provide the name and contact information for the STD program manager at [add high morbidity LHD here] that you suggest and return this information by replying to this email to [email protected]. Your completion of this information is entirely voluntary and takes approximately 15 minutes. There are no known risks or direct benefits to you from participating or not participating, but your responses will help Cloudburst Group identify individuals who can provide more feedback. No unique identifying information about you or the individual you list below will be published in any form or shared beyond the Cloudburst Group staff collecting this feedback. Also, your contact information will be secure and not shared.

Name	Email	Phone

Thank you for providing us with the contact of targeted staff from your local health department who can provide feedback about STD clinical partnerships. If you have any questions, please contact me at [email protected] or 301-385-6693.

Sincerely,

Dr. Steven Sullivan

Senior Project Director

[email protected]

301-385-6693

CDC estimates the average public reporting burden for this collection of information as 15 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 burden to CDC/ATSDR Information Collection Review Office; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0879).