Documentation of Interviews with AGE Crew Case Cabin Mat

Attachment 5d. Documentation of interviews to determine AGE illness status

Form approved
OMB No: 0920-XXXX
Expiration Date: XX/XX/20XX

Documentation of Interviews with AGE Crew Case Cabin Mates and Immediate Contacts to Determine AGE Illness Status

Crewmember Name:
AGE Illness Status:
Immediate Contact:
AGE Illness Status of Immediate Contact:
Interview Date:
Interview Time:
Interviewer:
Crewmember Name:
AGE Illness Status:
Immediate Contact:
AGE Illness Status of Immediate Contact:
Interview Date:
Interview Time:
Interviewer:
Crewmember Name:
AGE Illness Status:
Immediate Contact:
AGE Illness Status of Immediate Contact:
Interview Date:
Interview Time:
Interviewer:
Crewmember Name:
AGE Illness Status:
Immediate Contact:
AGE Illness Status of Immediate Contact:
Interview Date:
Interview Time:
Interviewer:

CDC estimates the average public reporting burden for this collection of information as 5 minutes per response, including the time for reviewing instructions, searching existing data/information sources, gathering and maintaining the data/information 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-XXXX).