Authorization for Transportation Arrangements

C

Attachment 3e

DC HEALTH SURVEY

AUTHORIZATION FOR TRANSPORTATION ARRANGEMENTS FOR

PERSONS Birth to 17 YEARS OF AGE

Proposed Changes to the currently approved form are noted using track changes

NAME OF CHILD: AGE:

 I consent to transportation of my child to and from the Mobile Exam Center/
Field Office by members of the CDC health survey staff.

 I consent to transportation of my child to and from the Mobile Exam Center/
Field Office in a taxi arranged and paid for by the CDC health survey.

 I will drive.

Children birth to 15 years old must come to the Mobile Exam Center accompanied by someone aged 18 and over. Please complete the subsequent section with this in mind. Children birth to 15 years old who arrive alone will not be examined.

 Mother will accompany.

 Father will accompany.

 Other person 18 and over will accompany _______________________

Specify

 Will come alone (only for children ages 16 and 17).

(Signature of Parent or Guardian) (Date)

SP ID __ __ __ __ __ __

(Witness)