ATSDR Public Meeting Survey Sign-In Sheet

ATSDR Communication Activities Survey (ACAS)

AttE ACAS Sign-in Sheet 20201130

Community Members - Sign-In Sheet

OMB: 0923-0055

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ATTACHMENT E. ACAS Sign In Sheet

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ATSDR estimates the average public reporting burden for this collection of information as 2 minutes per survey, 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 (0923-0055).

ATSDR Public Meeting Survey Sign-In Sheet

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Form Approved

OMB No. 0923-0055

Exp. Date 06/30/2020



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Form Approved

OMB No. 0923-0055

Exp. Date 06/30/2020

Name of Site: _____________________________________________

Address: _________________________________________________

Date of Community Meeting: _____________________________


CONSENT: Taking part in the ACAS is completely voluntary. The information on the sign in sheet will only be used to recruit and contact ACAS participants and for no other purpose. You may skip any question or stop at any time. Your responses and identity will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release information that may identify you in any ATSDR reports. Please be sure to get all of your questions about the survey answered by ATSDR before you begin. By proceeding, you indicate that you are 18 years of age or older, and CONSENT to participate in this survey.


Note: This information will not be shared with other agencies.


Email (for online survey only)

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File Typeapplication/vnd.openxmlformats-officedocument.wordprocessingml.document
AuthorOlivia Harris: NCEH/ATSDR Office of Science
File Modified0000-00-00
File Created2021-01-12

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