Landline screener - child

ATTACHMENT 5c -

ACBS LANDLINE SCREENER - CHILD

Form Approved

OMB Control No. 0920-1204

Exp. Date 11/30/2020

Recommended Permission Script

“We would like to call to you again within the next 2 days to talk in more detail about your child’s experiences with asthma. The information will be used to help develop and improve the asthma programs in <STATE>. The information you gave us today and any you give us in the future will be kept confidential. If you agree to this, we will keep your first name or initials and phone number on file, separate from the answers collected today. Even if you agree now, you may refuse to participate in the future. Would it be okay if we called you back to ask additional asthma-related questions at a later time?”

1 Yes

2 No

Can I please have either (your/your child’s) first name or initials so we will know who to ask for when we call back?

__________________ Enter first name or initials

CDC estimates the average public reporting burden for this collection of information as 1 minute 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 (No. 0920-1204, Exp. Date 11/30/2020).