0920-0109 Test Participant Information Sheet_18OCT2024

Test Participant Information Sheet
Name: ________________________

Form Approved
OMB No. 0920-0109
Exp. Date xx/xx/20xx

Date of Birth:____________

ID #: __________________
SSN #: _________________
Bank: __________________
Account #: _____________________
Bank Routing #: _________________

Address:____________________________
Phone Number:_______________ Cell:________________
E-Mail:___________________________
When Available for
Testing:____________________________________ Best Time to
Contact:_________________________________________

Public reporting burden of this collection of information is estimated to average 5 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-1031 Rev. 3