ATSDR Public Meeting Sign-In Sheet

ATTACHMENT E. Sign-In Sheet

ATSDR Public Meeting Survey Sign-In Sheet

Form Approved

OMB No. 0923-XXXX

Exp. Date MM/DD/YYYY

Name of Site: _____________________________________________

Address: __________________________________________________

Date of Community Meeting: _____________________________

ATSDR estimates the average public reporting burden for this collection of information as 2 minutes per survey, 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 (0923-xxxx).

CONSENT: Providing your contact information and taking part in this survey is completely voluntary. The information on the sign in sheet will only be used to recruit and contact ACAS participants and for no other purpose. You may skip any question or stop at any time. Your responses and identity will be kept private to the extent allowed by law. Digital data will be stored in secure computer files. We will not release your identity in any ATSDR reports. Please be sure to get all of your questions about the survey answered by ATSDR before you begin. By proceeding, you indicate that you are 18 years of age or older, and CONSENT to participate in this survey.

Note: This information will not be shared with other agencies.

	Name (please PRINT)	Which of these best describe you?	Street Address	City	State	Zip code	Phone Number for telephone survey (Time preference)	Email (for online survey)	How would you like to take the survey?
1		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
2		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
3		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
4		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
5		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
6		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
7		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
8		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
9		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
10		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
11		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
12		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
13		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
14		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
15		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
16		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
17		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
18		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
19		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
20		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
21		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
22		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
23		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
24		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
25		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
26		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
27		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
28		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
29		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
30		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
31		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
32		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
33		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
34		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
35		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
36		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
37		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
38		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
39		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone
40		Community member Stakeholder Federal State Local Other (specify):________________					Phone Number: Morning Afternoon Evening		In person Online Telephone

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