Recruitment Verification Form

Form Approved

OMB No. 0920-0840

Expiration Date: 01/31/2019

Pathways: Qualitative Interviews with Post-Partum Women Associated with Congenital Syphilis Cases (Case Mothers)

Generic Information Collection Request under OMB #0920-0840

Attachment #3b

Recruitment Verification Form

Public reporting burden of this collection of information is estimated to average 0 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-0840)

RECRUITMENT VERIFICATION FORM

HD ID:

DIS/HD Staff:

DATE:

NAME:

PHONE:

EMAIL:

WILLING TO PARTICIPATE: YES NO

VERBAL CONSENT TO CONTACT: YES: ______phone _____email ____NO

ABLE TO CONVERSE IN ENGLISH: YES NO

ANY LIMITATIONS/NOTES (e.g., dates not available, questions asked):

3