Form 0920-21DC Nonresponse Survey

Attachment # 6

Form Approved

OMB No. 0920-New

Expiration Date: XX/XX/XXXX

National Syringe Services Program Evaluation

Nonresponse Survey Item

Public reporting burden of this collection of information is estimated to average 2 minutes, including the time for reviewing instructions, administering questions and entering responses. 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 Reports Clearance Officer; 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; Attn: OMB-PRA (0920-New)

Nonresponse Survey Item

Please consider answering one question about why you were not able to participate in the survey so that we can improve future surveys.

1. Please indicate why you were not able to participate in the survey [select all that apply]

• No time/too busy

• The survey is too long

• The information asked about in the survey is hard to recall

• Concern that data from my program will not be kept confidential

• None of the options for completing the survey were convenient for me

• Our program has already completed similar surveys

Other, please specify:___________________________

Thank you for your time!