Form No number No number HABISS

Attachment 3 0920 0004 Change Request 9 22 08

Screen shots of Data Collection Instrument

OMB No.: 0920-0004

Expiration: 10/2010

Public reporting burden for this collection of information is estimated to average 8 hours 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 Information Collection Review Office; 1600 Clifton Road NE, M.S. D-74; Atlanta, Ga. 30333; ATTN: Paperwork Reduction Act Project (0920-0004)

OMB No. : 0920-0004

Expiration: 10/2010