0920 Eligibility Screener

Form Approved

OMB No. 0920-xxxx

Expiration Date: XX/XX/XXXX

Evaluation of safe spaces in CDC-directly funded community-based organizations

Attachment 3

Eligibility Screener

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: OMB-PRA (0920-New)

Safe Spaces Evaluation Client Eligibility Screener

CBO Name: ___________________________

Date: ___________________________

Hello. My organization is interested in how people like [safe space name]. I would like to give you a brief, 15-minute survey about your experiences in [safe space name]. If you are eligible and want to participate, you may take the survey here or I can send you a link to complete the survey somewhere else. First, I need to determine if you are eligible to take the survey.

1. Would you like to participate in a 15-minute anonymous survey? You will be given [description of token of appreciation] for your time.

☐ Yes

☐ No

2. Have you taken a survey about [safe space name] before?

☐ Yes

☐ No

3. Are you 18 years of age or over?

☐ Yes

☐ No