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Form Approved

OMB No. 0923-17IY

Exp. Date xx/xx/201x

Attachment 5b. Eligibility Screening Survey for Licensed Anglers (paper)

Instructions:

• Please complete this paper survey and return it in the stamped addressed envelope.

OR

• You can complete the survey online at [LINK TO ONLINE SURVEY]. If you fill out this form online, you do not need to return this survey in the mail.

ATSDR estimates the average public reporting burden for this collection of information as 5 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 (0923-17IY).

[INSERT NAME]

Please correct the information below if it is not your current address:

[INSERT STREET ADDRESS]

[INSERT CITY, STATE, ZIPCODE

Please check Yes or No for each of the following questions:	Yes	No
1. I have lived at my current address for one year or longer.
2. I am a male OR I am a female who is not currently pregnant
3. In the past 12 months, I ate at least one fish meal that was caught in any of the lakes, rivers, streams, or ponds pictured in the map printed on the back of this page.

Please fill out the information below if you are interested in participating in the Milwaukee Angler Project. (This information will be used for this project only.)

Email address: ____________________________________________

Telephone numbers where we can reach you:

Cell: (_______) ________ - ______________ Can we send you text messages? Yes No

Home: (_______) ________ - ______________

Work: (_______) ________ - ______________

Check the best days and times to reach you by telephone.

	Mon.	Tues.	Wed.	Thurs.	Fri.	Sat.	Sun.
Morning
Afternoon
Evening

Thank you for filling out this survey and returning it to us. A staff member may contact you in the next week or two if you are a good fit for this project.

Map of the waterbodies of interest

File Type	application/vnd.openxmlformats-officedocument.wordprocessingml.document
Author	wdw0
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File Created	2021-01-21