Form 0920-24AL Expression of Interest Form

Form Approved

OMB No. XXX

Exp. Date XX/XX/XXXX

Expression of Interest Form

Thank you for your potential interest in participating in the NIOSH study “Occupational exposures to surgical smoke in veterinary personnel.”

To express interest in participating in this research study, please fill out this 3-question form:

1. *First and last name: _____________________________________________________________

2. *Email address: _________________________________________________________________

3. Phone number: __ __ __ - __ __ __ - __ __ __ __

*Required

If you prefer, you may alternatively email us at iun8@cdc.gov (Dr. Fechter-Leggett) or qdk5@cdc.gov (Dr. Anderson) to express interest in participating.

After you submit this form, a study Co-PI will reach out to you to schedule a day/time, at your convenience, to complete the informed consent and baseline questionnaire. We will provide you with the informed consent form ahead of time for you to review. We can also answer any questions you have.

This study is being led by Co-PIs, Ethan Fechter-Leggett, DVM, MPVM and Kim Anderson, PhD. Please reach out to us with any question at any time:

Ethan Fechter-Leggett, DVM, MPVM

Research Epidemiologist

NIOSH Respiratory Health Division

iun8@cdc.gov

304-285-6030

Kim Anderson, PhD

Research Industrial Hygienist

NIOSH Respiratory Health Division

qdk5@cdc.gov

304-285-6321

Public reporting burden of this collection of information is estimated to average 3 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 H21-8, Atlanta, Georgia 30333 ATTN: PRA (0920-XXXX).