EQUIP Enrollment Form

Form Approved
OMB No. 0920-xxxx
Exp. Date xx/xx/20xx

Laboratory Enrollment Form
Date 12/15/2020

Laboratory Information
�
Laboratory Name
Phone Number

Fax Number

General Laboratory E-mail Address (If applicable)

Website

Mailing Address

Shipping Address (

Address

Address

City

City

State/Province

State/Province

Zip/Postal Code

Zip/Postal Code

Country

Country

Same as mailing address.)

Requestor Information
Mr.

Mrs.

Ms.

First Name

Dr.
Last Name

Degree(s)
MD

Title/Position
Ph.D.

Phone Number

Other
Fax Number

E-mail Address

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-xxxx).
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