Reinterview Study Questionnaire

Form Approved
OMB No. 0920-0234
Exp. Date xx/xx/20xx

Attachment Q: 2019 NAMCS Reinterview Study Questionnaire
Notice- CDC estimates the average public reporting burden for this collection of information as
30 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 (0920-0234).
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.