0920-20PR Participant Data Collection Form

Form Approved OMB No. 0920-XXXX

Exp. Date xx/xx/20xx

Instrument C

PARTICIPANT DATA COLLECTION FORM

Participant #: _____________________ Date/Time: _____________________

1. Consent Form: YES | NO Copy to subject: YES | NO

2. Sex: Male | Female

   1. Pregnant: YES | NO

3. Date of Birth: ___________

4. Job experience

   1. Current employee: ___________

2. Years of working in the manufacturing industry: _______ years

Public reporting burden of this collection of information is estimated to average 1 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-XXXX).

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