Form TEB-1023 Rev.1 TEB-1023 Rev.1 Subject Template (Fit test STP 5_5.1_6)

Subject Template Form Approved

OMB No. 0920-0109

Exp. Date xx/xx/20xx

TN: _____________________________________ Date: _____________________________

Manufacture: _____________________________

Size	Name	Time	Mask Size	Mask Size	Mask Size	Remarks

Public reporting burden of this collection of information is estimated to average 10 minutes per response, including the time for
reviewing instruction, 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/ATSD Information Collection Review
Office, 1600 Clifton Road NE, MS D-74, Atlanta, Georgia 30333; ATTN: PRA (0920-0109).

TEB-1023 Rev. 1