Form Approved
OMB #:0920-0572
Expiration Date: 08/31/2021
Instruction (to be read to participant): Now that you have reviewed the fact sheet and answered some initial questions, we will share our screen with you and ask you to provide your response for each of these statements aloud. Are you ready to begin?
How much do you agree or disagree with the following statements? (Please check ONE response for each item)
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Strongly Disagree |
Disagree |
Neither Agree Nor Disagree
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Agree |
Strongly Agree |
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1. |
The information on this fact sheet is clear and easy to understand. |
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2. |
If I received this fact sheet during a public health emergency, I would read it. |
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3. |
I am confident that I could find the medicine instructions on this fact sheet. |
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4. |
I am confident that I can follow the medicine instructions on this fact sheet. |
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5. |
I understand the risks and benefits of taking this medicine. |
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6. |
This fact sheet provides all the necessary information for me to decide whether or not I would take the medicine and/or give to my child. |
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Public reporting burden of this collection of information is estimated to average 65 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 (0920-0572).
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Panne Burke |
| File Modified | 0000-00-00 |
| File Created | 2021-01-15 |