Form 0920-0943 RCC/ADSC Contact Confirmation Call Script

Attachment F

Contact Confirmation Call Script

Form Approved

OMB No. 0920-0943

Exp. Date xx/xx/20xx

NOTICE – Public reporting burden for the contact verification is estimated to average 5 minutes per response. 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 Reports Clearance Officer, 1600 Clifton Road, MS D-74, Atlanta, GA 30333, ATTN: PRA (0920-0943).

Assurance of Confidentiality – We take your privacy very seriously. All information that relates to or describes identifiable characteristics of individuals, a practice, or an establishment will be used only for statistical purposes. NCHS staff, contractors, and agents will not disclose or release responses in identifiable form without the consent of the individual or establishment in accordance with section 308(d) of the Public Health Service Act (42 U.S.C. 242m(d)) and the Confidential Information Protection and Statistical Efficiency Act of 2002 (CIPSEA, Title 5 of Public Law 107-347). In accordance with CIPSEA, every NCHS employee, contractor, and agent has taken an oath and is subject to a jail term of up to five years, a fine of up to $250,000, or both if he or she willfully discloses ANY identifiable information about you. In addition, NCHS complies with the Federal Cybersecurity Enhancement Act of 2015 (6 U.S.C. §§ 151 and 151 note). This law requires the federal government to protect federal computer networks by using computer security programs to identify cybersecurity risks like hacking, internet attacks, and other security weaknesses. If information sent through government networks triggers a cyber threat indicator, the information may be intercepted and reviewed for cyber threats by computer network experts working for, or on behalf, of the government.

• Hello, my name is [name of field interviewer] with [contractor name], representing the National Center for Health Statistics. I have some information that I would like to mail [you at/the current director or administrator of] [FILL FACILITY NAME]. IF NAME ON FRAME: May I please verify [your/this person’s] name? I have [your name/the name of the director or administrator] as [name of the director/administrator] SPELL IF NECESSARY. Is this correct? IF NAME NOT ON FRAME: May I please have [your correct/the current director’s or administrator’s] name? SPELL ALOUD TO CONFIRM SPELLING.

• I would also like to verify the name and street address of this residential care community/adult day services center.

  • I have the name of this residential care community/adult day services center as [name of residential care community/adult day services center] SPELL IF NECESSARY. Is this correct?

  • I have the street address of this residential care community/adult day services center as [street address of residential care community/adult day services center]. Is this correct?

• The number I called is [xxx-xxx-xxxx]. Is this the correct number to reach [you/name of director/administrator]? REPEAT TO VERIFY Is there an extension?

• What is [your/director’s/administrator’s name] email address? SPELL ALOUD TO VERIFY.

• May we call [you/name of director/administrator] on [your/her/his] work cell phone and, if so, what is that number? REPEAT TO VERIFY

• Thank you. I will put this information in the mail within [number] business days. Have a good day. Good bye.