Form 0920-1122 English Contact Information Form

Form Approved

OMB Number 0920-1122

Exp. Date: XX/XX/20Xx

Attachment 18 – Contact Information Form

Thank you for providing your child’s contact information. The findings from the survey will help current adults who were born with heart conditions and the future lives of children born with heart conditions.

Your Name

Your current name:

First name Last name

Your name at the time of your child’s birth:

First name Last name

Your Child’s Contact Information

Child’s current name:

First name Last name

Child’s name at birth:

First name Last name

Child’s phone number:

(xxx) xxx-xxxx

Child’s address:

Number and Street Apartment Number

City State Zip Code

Child’s email address:

Public reporting burden of this collection information is estimated to average 2 minutes, including 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, GA 30333: ATTN: PRA (0920-1122).