Example Questionnaire - Undetermined Exposure

Attachment E4. Example Questionnaire for Undetermined Exposure and Undetermined Risk
Factor

Form Approved
OMB No. 0920-1255
Exp. Date 03/31/2021

CDC estimates the average public reporting burden for this collection of information as 15 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 (0920-1255)

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Factor

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Factor

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Factor

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