Nonresponse Survey Item

Attachment # 3e

Nonresponse Survey Item

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

CDC estimates the average public reporting burden for this collection of information as 2

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).

Please consider answering one question about why you were not able to participate in the survey so that we can improve future surveys.

1. Please indicate why you were not able to participate in the survey [select all that apply]

• I have no time/too busy

• The survey is too long

• The information asked about in the survey is too difficult to retrieve

• I am concerned that data from my program will not be kept confidential

• None of the options for completing the survey were convenient for me

• Our program has already completed similar survey(s)

  • Please specify name of similar survey(s)

Other, please specify:___________________________

Thank you for your time!