Project Information Sheet

Form Approved

OMB Control No.: 0920-XXXX

Expiration date: XX/XX/XXXX

Project Information Sheet

Thank you for your interest in our project, “Homeless service providers’ knowledge, attitudes, and practices regarding body lice, fleas and associated diseases.” We are interested to learn about homeless service providers’ knowledge and attitudes about flea and lice-borne diseases among people experiencing homelessness. As someone who provides direct services and/or outreach to people experiencing homelessness, we invite you to participate in a survey. This survey will take approximately 10-15 minutes of your time. Participation is completely voluntary. You may choose not to answer any question and you may stop at any time. After completion of the survey, we will give you a $25 gift card to thank you for your time. Your answers will be anonymous and cannot be linked with any information that could personally identify you.

Results from this project will be used to improve efforts to prevent flea- and lice-borne diseases among people experiencing homelessness, identify areas for improvement in services provided to people experiencing homelessness, and develop educational materials for homeless service providers.

This investigation is being conducted by the US Centers for Disease Control and Prevention (CDC) and [local partner].

Please keep a copy of this form for your records.

Principal Investigator:

Grace E. Marx, MD, MPH

Medical Officer, Centers for Disease Control and Prevention

Email: [email protected]

Phone: (970) 568-6523

Public reporting burden of this collection of information is estimated to average 5 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data 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 Reports Clearance Officer, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA 0920-XXXX