CureTB Partner Feedback (at time of patient referral)

Form Approved

Page 1
Blue and red text are notations added after the PDF generation in
REDCap for clearance review and will not show on actual online
questionnaire.

1

OMB No. 0920-1186

Exp. Date 02/29/2024

If yes, question 2 will appear.
If no, next question is 6.

2

If other, question 3 & 4 will appear.
If any other option selected, next question is 4.

3

4

If any selected, question 5 will appear.
5

6

If yes, questions 7 will appear.
If no, next question is 9.

7

If any selected, question is 8 will appear.
8

Blue and red text are notations added after the PDF generation in
REDCap for clearance review and will not show on actual online
questionnaire.

Page 1 continued

If no, question 10 will appear.
If yes, next question is 11.

9

10
If no or partially, question 12 will appear.
11

If yes, next question is 13.

12

13

If no or partially, question 14 will appear.
If yes, next question is 15.

14

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16

CDC estimates the average public reporting burden for this collection of information as 10 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
(0920-1186).